Anesthesia Coding Alert

Establishing dual necessity unlocks reimbursement.

If your anesthesiologist is having trouble getting Medicare reimbursement for monitored anesthesia care (MAC) for endoscopy procedures, it might be time to clarify exactly what is meant by medical necessity.

Medicare defines medical necessity as services or items reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. Under the Social Security Act, CMS determines on a case-by-case basis if the method of treating a patient is reasonable and necessary. Even if a service is reasonable and necessary, coverage may be limited or denied if it is provided more frequently than allowed under a coverage policy, or as accepted standard of practice.

First: Establish Necessity for Endoscopy

CMS states that endoscopic procedures -- a technique in which a long flexible tube-like instrument is inserted into the body orally or rectally -- are covered when reasonable and necessary for the individual patient.

Circumstances that establish the medical necessity for endoscopic procedures are patients who have more complex procedures such as endoscopic retrograde cholangiopancreatography (ERCP) or endoscopic ultrasound (EUS); patients who are pregnant;patients who have cancer, epilepsy, or seizure disorders; children 18 years or younger;and seniors 65 or older, says Darlene Ogbuagu, CPC, ACS-AN, in Chicago.

In addition, patients with danger of airway compromise with a history of sleep apnea, Down syndrome, oral abnormalities, and/or patients who are combative, abuse drugs, or have intolerance to sedatives may require endoscopy, Ogbuagu says.

Next: Reasons for MAC Establish Necessity

The patient should have a medical condition significant enough to impact the need to provide MAC, says Cindy Smith, CPC, with Professional Healthcare Billing Services in Charleston, W.V.

Some Medicare providers do have guidelines for MAC, which includes the endoscopy codes, Smith adds. When you code for these procedures, code with the reason for the MAC along with the reason for the procedure, if applicable.

For instance: Examples of conditions that support medical necessity for MAC include but are not limited to the following:

" 250.00-250.03 -- Diabetes mellitus without mention of complication

" 278.01 -- Morbid obesity

" 401.9 -- Essential hypertension; unspecified

" 403.01-403.11 -- Hypertensive chronic kidney disease

" 410.00-410.02 -- Acute myocardial infarction

" 997.00 -- Nervous system complications,unspecified.

The patients record should document appropriate history and physical examination by your anesthesiologist that specifies the medical indications requiring the use of deep sedation.

Finally: Cite Circumstances for Endoscopy

Your anesthesiologists documentation must explain the circumstances under which the service was provided. Both your anesthesiologist as well as the endoscopist should record these indications in their individual documents. The supporting documentation should identify patient-specific reasons for MAC, such as:

" Reports from previous endoscopies that indicate difficulties in completing the procedure

" Unusual discomfort during the procedure

" Evidence of an unstable medical condition, such as those diagnosis codes listed above.

To establish medical necessity for MAC endoscopy,anesthesia providers can document when other medical specialists are not trained to treat patients with anesthesia risk factors that require the involvement of an anesthesiologist.Conditions include co-morbidities with ASA P3-P5 grades, airway obstruction risk factors, and other underlying risk factors, says Ogbuagu.

If known ahead of time, the anesthesia practice should obtain insurance pre-certification for patients undergoing prolonged or complex procedures requiring anesthesia services for patients with gastrointestinal bleeding, lung, cardiac or renal disease, and obesity,Ogbuagu adds. In addition to providing documentation that proves patient safety and comfort, the medical diagnosis should support the procedure and/or level of service.

Currently there is no national policy for anesthesia and endoscopy, so it is vitally important to your financial health to know your local carrier policies with regard to reimbursement.