Medicare Compliance & Reimbursement

Question: Our internal medicine doctors want the anesthesiologists to set up a system for routine anesthesia sedation of difficult to sedate patients. Do Medicare, Medicaid, and commercial insurances pay for this? What type of documentation do we need to do to prove medical necessity and to get paid?

Colorado Subscriber

Answer: Anesthesiologists do not usually bill for conscious sedation. Sedation is provided by either the physician performing the service, or a qualified health care professional (QHCP). Moderate sedation codes, ranging from 99151-99153 (Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports …) to 99155-99157 (Moderate sedation services provided by a physician or other qualified health care professional other than the physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation support …), would be reported by the internal medicine group, not an anesthesia group.

When you review the Moderate (Conscious) Sedation section of CPT^®, you will notice that moderate sedation codes “are not used to report administration of medications for pain control, minimal sedation (anxiolysis), deep sedation or monitored anesthesia care (00100 – 01999).” When an anesthesiologist provides this type of sedation, they keep anesthesia records and bill services using the anesthesia codes, which does require medical necessity.

Medical necessity will depend on the procedure and/or the patient and documentation must support the reason anesthesia was provided, rather than sedation.

If medical necessity is in question, the patient can sign a waiver of liability. This is similar to Medicare’s advanced beneficiary notice (ABN), which the patient should agree to before the surgery to pay for the costs if insurance does not cover. The form may be adapted for use and may be accepted by some private payers. However, it is best to check your commercial payers to see if they have a process that differs or their own form, as not all of them accept Medicare’s ABN.