Gastroenterology Coding Alert

Most gastroenterologists use conscious sedation during ambulatory endoscopies but find that receiving reimbursement for this form of anesthesia is difficult at best.

Many carriers' general guidelines regarding conscious sedation also apply to ambulatory surgical centers. Considering that the use of the conscious-sedation drug propofol is growing in popularity, you may have several questions regarding coding for this service in your practice.

Medicare's Policy for ASCs

The Medicare Carriers Manual states that coverage of ASC services includes not only the surgery but also "services furnished in an ASC in connection with a covered surgical procedure which are otherwise covered if furnished on an inpatient or outpatient basis in a hospital in connection with that procedure." This does include materials for anesthesia: the anesthesia itself and any materials needed for its administration. ASC policy holds true to existing policy regarding surgeries performed in hospitals. If a physician usually charges a global surgery fee, then this same approach is used when a physician performs the same procedure in an ASC.

The issue of anesthesia directly affects you because several gastrointestinal endoscopies require anesthesia, whether general anesthesia or conscious sedation. Included in this category are the upper gastrointestinal endoscopies (43235) and colonoscopies (45378-45387).

Billing for Propofol

There are unresolved issues regarding the anesthesia used in many of the ambulatory gastrointestinal endoscopies. Conscious sedation is the most common type of sedation used for these procedures. This type of sedation is preferred because it is "used to achieve a medically controlled state of depressed consciousness while maintaining the patient's airway, protective reflexes, and ability to respond to stimulation or verbal commands," according to CPT guidelines . Drugs most commonly used for conscious sedation include meperidine (Demerol), diazepam (Valium), and midazolam (Versed). These are included in the analgesic category of anesthesia drugs.

However, a second group of drugs is gaining notoriety: anesthetic induction agents, including such drugs as ketamine (Ketalar) and propofol (Diprivan). Pat Stout, CMC, CPC, an independent gastroenterology coding consultant and president of OneSource, a medical billing company in Knoxville, Tenn., says that propofol is becoming popular because it can be used without the after effects of other drugs. For example, the wake-up period is shortened, the need for transportation is often skipped, and time is saved in the recovery room.

But gastroenterologists are facing some problems with the use of propofol. There is a question as to whether propofol is conscious sedation or not, Stout says. This question does not have a general answer, since many states differ in their local policies. If it is classified as general anesthesia, an anesthesiologist has to give it. The issue with this is that Medicare only approves anesthesia for reimbursement if the patient is a risk 3, which means he has a severe systemic disease.

According to Fran Schultz, RN, associate manager medical procedures unit at the University of Michigan, the state practice laws in Michigan say that "for propofol to be used an anesthesiologist must be present because the anesthesiology department oversees all forms of sedation in Michigan." The only people qualified to either administer or oversee the administration of propofol are anesthesiologists or CRNAs. Schultz says the use of propofol in endoscopies has brought good results, but gastroenterologists are hitting dead ends in her state when trying to use this drug.

Many doctors are against using propofol because having the required specialists in the room adds cost to the procedure. She says the reason for such tight restrictions is that the drug is more dangerous than others. "Specialists need to be present to rescue the patient who gets into difficulty, monitor the patient in-depth, and perform emergency rescue operations," Schultz says.

Because use of propofol is becoming widespread, you need to ask your local carrier for its policy on propofol's use and reimbursement. Determine if the drug can be given as conscious sedation or general anesthesia only. Either way, Medicare tends to be stiff on its coverage of conscious sedation. Some private carriers tend to follow Medicare's lead on ASC reimbursement. It considers this procedure to be bundled in with the surgery package.

Most gastroenterologists do not bill to Medicare but only to private payers. For example, a patient comes into the ASC for a routine colonoscopy, and propofol is administered by the gastroenterologist. This classifies as conscious sedation, and the appropriate code should be used: 99141 (Sedation with or without analgesia [conscious sedation]; intravenous, intramuscular or inhalation) or 99142 (... oral, rectal and/or intranasal).

Most commercial payers follow Medicare guidelines and will not pay for conscious sedation. However, you can try to code for the drug and its supply. According to Cindy Parman, CPC, CPC-H, RCC, Coding Strategies Inc., there is no code that specifically describes the drug propofol. You have two options: J3490 (Unclassified drugs) and 99070 (Supplies and materials [except spectacles], provided by the physician over and above those usually included with the office visit or other services rendered [list drugs, trays, supplies, or materials provided]).