Anesthesia Coding Alert

Hint: It could depend on medical necessity Carrier guidelines and surgeon preferences related to anesthesia during gastrointestinal (GI) endoscopic procedures are all over the board - and the need for anesthesia during these procedures is a political hot button these days. If you've struggled with how to handle coding for these cases, read on for some basic guidelines that will keep you on track. Why Is It an Issue? Surgeons might perform conscious sedation during endoscopic procedures, but they  sometimes ask a member of the anesthesia team to provide anesthesia instead. Rationale: Reasons can vary according to the circumstances, but here are two possibilities:
  The surgeon might not meet the criteria for reporting conscious sedation codes 99141 (Sedation with or without analgesia [conscious sedation]; intravenous, intramuscular or inhalation) or 99142 (... oral, rectal and/or intranasal). Before a surgeon can bill conscious sedation in addition to the endoscopic procedure, a "qualified professional" such as a nurse must provide and document monitoring at regular intervals during the case (such as the patient's heart rate, blood pressure and pulse oximetry).
  The surgeon may be experiencing bad outcomes during conscious sedation he administers or may be leery of bad outcomes. For example, patients with chronic conditions, "spastic" conditions or dementia are riskier to perform otherwise routine procedures on. "Wanting anesthesia's involvement may be about the surgeon's level of risk or malpractice issues if the patient is not considered a healthy, routine endoscopic evaluation," says Julee Shiley, CPC, a South Carolina coding consultant. "It's riskier for physicians to perform procedures on these patients, and the patients might require more monitoring for sedation."

Note: Some states consider sedation to be an important part of the endoscopy procedure, which means it is included in the global fee. Because of this, it would be very unlikely for the surgeon to bill conscious sedation with the endoscopy, so check your state's regulations.

Medical Necessity Is Your Justification When the surgeon asks your physician to provide anesthesia during endoscopy, the first step toward receiving payment is proving medical necessity.

"If there are no known conditions that justify an anesthesia professional's involvement, the carrier may not consider it to be medically necessary," Shiley says. However, if the surgeon requests anesthesia administration because of known conditions that require additional monitoring, Shiley says it is reasonable - and wise - to charge separately for the anesthesia.
 
Conditions that help justify anesthesia's use because of additional monitoring include:
hypertensive disease (401-405)

heart disease (such as 425.4, Cardiomyopathy; 416.x, Chronic pulmonary heart disease; and 496, Chronic airway obstruction, not elsewhere classified)

diabetes (250.xx)

stroke (434.xx)

Parkinson's disease (332.x)

epilepsy (345.xx). Medical-necessity policies are carrier-specific and can even vary according to the patient's current [...]