# Question regarding "deep sedation"



## LINDA (Dec 1, 2009)

I code for Neonatologists who provide critical newborn care.  They are  occassionally asked by the surgeon to provide "deep sedation" - in the NICU for a patient undergoing a surgical procedure.  My understanding is that this is different from "Conscious (moderate) sedation", so I cannot use that code.  To my knowledge, there isn't a code for "deep sedation".  Should I use the general anesthesia codes?  If so, how would that affect billing for the daily NICU visit since these are our patients in the first place.  The anesthesia codes are not bundled into the global services for NICU E/M coding, but wouldn't the daily visit then be part of the Anesthesia service and fall under the global guidelines for Anesthesia?  Also, does anyone know if any payors would require Anesthesia to be billed only by Anesthesiologists, as obviously we are not.  I would appreciate any input.  I've never done Anesthesia coding, so I'm a little rusty on these details.


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## LeslieJ (Dec 3, 2009)

Anesthesia codes are designed to be used by trained physicians and/or their assistants to provide anesthesia services.

Having said that, you need to understand what's involved with these services is more than giving the patient a sedative and voila, they go off to sleep.

The following documentation elements comes form CMS' Internet Only Manuals, 100-04, Chapter 12, Section 50, and although not specifically mentioned here, this pretty much also includes most all of the sedation techniques used.

The physician and/or trained assistant:

• Performs a pre-anesthetic examination and evaluation;
• Prescribes the anesthesia plan;
• Personally participates in the most demanding procedures in the anesthesia plan, including induction and emergence;
• Ensures that any procedures in the anesthesia plan that he or she does not perform are performed by a qualified anesthetist;
• Monitors the course of anesthesia administration at frequent intervals;
• Remains physically present and available for immediate diagnosis and treatment of emergencies; and
• Provides indicated-post-anesthesia care.

Section 50 starts on page 117 http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf

Now to tell the difference between the types of anesthesia & who can do what, first see here:  http://www.asahq.org/publicationsAndServices/standards/20.pdf

This is the Continuum of Depth of Sedation that tells you "how deep is "Deep"?" per the guidelines by the ASA.

Most insurance companies will only allow an anesthesiologist or CRNA (certified Nurse Anesthetist) to administer anesthesia services at the levels you seem to be talking about.  Yes, those levels require not only a trained observer, but one who is trained in airway & cardiac rescue should either of these become compromised during the procedures.

Only Anesthesiologists and/or CRNA may use the anesthesia codes 00100-01999.   The payment for these codes isn't flat-fee like other procedures.  Payment is determined by the amount of time units + base units for the procedure + any qualifying circumstances (like age, emergency services, others)  units multiplied by a conversion factor rate (dollar paid per unit).

If a surgeon administers his/her own anesthetic and has a trained observer (nurse or other MD) watching over the patient, the correct codes are 9914x - 99150. Payment for this is pretty much based on flat-fee depending on how much time was spent.  Anesthesiologists & CRNA can't use those particular codes.  

In answer to your questions about how the payers react - I honestly don't know any payer who allows surgeons to use the anesthesia codes nor any that allow an anesthesiologist to use the 9914x sedation codes.  You have a situation where it's going to be either/OR.

Per the ASA, "deep sedation" is pretty deep and should only be done by anesthesiologists and/or CRNA.  This would mean the anesthesia codes would be used, IMHO, and not by the surgeons.

I hope this helps you start to get some answers.

L J


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