Monday, July 12, 2010

Anesthesia services - Gastrointestinal endoscopy - CPT 00740 , 00810

Use of Anesthesia Services for Routine Gastrointestinal Endoscopy

As a general rule, benefits are payable under Blue Cross and Blue Shield of Alabama health plans only in cases of medical necessity and only if services or supplies are not investigational, provided the customer group contracts have such coverage.

The following Association Technology Evaluation Criteria must be met for a service/supply to be
considered for coverage:

1. The technology must have final approval from the appropriate government regulatory bodies;

2. The scientific evidence must permit conclusions concerning the effect of the technology on health outcomes;

3. The technology must improve the net health outcome;

4. The technology must be as beneficial as any established alternatives;

5. The improvement must be attainable outside the investigational setting.

Coding:

CPT Codes:

00740 Anesthesia for upper gastrointestinal endoscopic procedures, endoscope introduced proximal to duodenum

00810 Anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum.

00530 - Anesthesia for permanent transvenous pacemaker insertion

00532 - Anesthesia for access to central venous circulation

00702 - Anesthesia for procedures on upper anterior abdominal wall; percutaneous liver biopsy

0920 - Anesthesia for procedures on male genitalia (including open urethral procedures); not otherwise specified

01420 - Anesthesia for all cast applications, removal, or repair involving knee joint

01730 - Anesthesia for all closed procedures on humerus and elbow


Description of Procedure or Service:


Intravenous sedation and analgesia is routinely administered for gastrointestinal endoscopic examinations to help alleviate patient anxiety and discomfort. Provision of sedation and analgesia for endoscopy procedures is standard practice. In the United States, licensed registered nurse or physician assistant administration of intravenous opiate narcotic, usually meperidine (Demerol®), in combination with a benzodiazepine, usually midazolam (Versed®), under the direct supervision of a licensed physician endoscopist is the traditional method for achieving sedation.

Recently propofol (Diprivan) has been used as an alternative method of sedation for patients undergoing endoscopy procedures. Propofol is a short-acting anesthetic agent. The advantages of propofol are its rapid induction of sedation, quicker patient recovery time, and anti-emetic effect. The use of propofol requires monitoring for respiratory and/or cardiac collapse by trained personnel.


CPT modifier 76 – Repeat Procedure or Service by Same Physician

The patient is returned to the operating room on the same day for the same or a related procedure. The same physician who is performing the repeat service should bill the repeat procedure with the 76 CPT modifi er.


Example 

Provider          Date of Service         CPT Code           Modifier


ABC Medical Group 01/01/2013 00740 HCPCS Modifi er AA-First Service


CPT Modifier 77 – Repeat Procedure by Another Physician

When a patient is taken back to surgery on the same day for the same or a related procedure by a different physician than the physician who performed the first service, submit the repeat procedure with the 77 CPT modifier.

Example

Provider          Date of Service         CPT code          Modifier

ABC Medical Group 01/01/2013 00740 HCPCS Modifi er AA-First Service

Monitored Anesthesia Care

With advances in modern medical technology, there has been a shift in supplying some surgical and diagnostic services to an ambulatory, outpatient or office setting. Accompanying this, there has been a change in the provision of anesthesia services from the traditional general anesthetic to a  combination of local, regional and certain mind-altering drugs. This type of anesthesia is referred to as monitored anesthesia care (MAC) if directly provided by anesthesia personnel. MAC requires careful and continuous evaluation of various vital physiologic functions and the diagnosis and treatment of any deviations. This type of anesthesia can be provided by a variety of qualified anesthesia personnel.

Coverage for MAC is allowed if the anesthesia service is medically reasonable and necessary and if the procedure for which MAC is given is itself a Medicare benefit and is medically reasonable and necessary.

1. In keeping with the American Society of Anesthesiologists' standards for monitoring, MAC should be provided by qualified anesthesia personnel, (anesthesiologists or qualified anesthetists such as certified registered nurse anesthetists or anesthesia assistants). These individuals must be continuously present to monitor the patient and provide anesthesia care.

2. During MAC, the patient's oxygenation, ventilation, circulation and temperature should be evaluated by whatever method is deemed most suitable by the attending anesthetist. Close monitoring is necessary to anticipate the need for general anesthesia administration or for the treatment of adverse physiologic reactions such as hypotension, excessive pain, difficulty breathing, arrhythmias, adverse drug reactions, etc. In addition, the possibility that the surgical procedure may become more extensive, and/or result in unforeseen complications, requires comprehensive monitoring and/or anesthetic intervention.

3. The following CMS requirements for this type of anesthesia should be the same as for general anesthesia with regards to the performance of pre-anesthetic examination and evaluation, prescription of the anesthesia care required, the completion of an anesthesia record, the administration of necessary oral or parenteral medications and the provision of indicated post-operative anesthesia care. Appropriate documentation must be available to reflect pre and post-anesthetic evaluations and intraoperative monitoring.

4. The MAC service rendered must be appropriate and medically reasonable and necessary.

5. Anesthesia procedures listed in the CPT/HCPCS section are usually provided by the attending surgeon and are included in the global fee and are not separately billable. In certain instances, however, MAC provided by anesthesia personnel may be necessary for these procedures. This is true if there are one or more of the co-existing conditions present that are listed below under the ICD-10-CM code list. In this situation, the appropriate MAC modifier is QS, which should be billed along with the appropriate ICD-10-CM Code for the co-existing condition(s). Second the MAC modifier G8 can be used with the anesthesia services listed below and indicates that the surgical procedure is deep, complex, complicated or markedly invasive. These services include only procedures on the face (00100 and 00160); head, neck, and posterior trunk (00300); breast (00400), or genitalia (00920) and for access to the central venous circulation (00532). These CPT codes themselves do not differentiate complexity. The MAC modifier G9 is used with an anesthesia code to indicate that the patient has a history of a severe cardiopulmonary condition.

In summary, MAC may be necessary and justified for the CPT/HCPCS procedures with the QS modifier if a co-existing condition exists, or if the procedure qualifies for a G8 modifier.

6. Reimbursement for MAC will be the same amount allowed for full general anesthesia services if all the requirements listed under these indications are met. No additional reimbursement is allowed with the use of modifiers (e.g., G8, G9). The provision of quality MAC is mandatory and requires the same expertise and the same effort (work) as required in the delivery of a general anesthetic. If the requirements are not fulfilled or the procedures are unnecessary, payment will be denied in full.

7. The presence of an underlying condition alone, as reported by an ICD-10-CM code, may not be sufficient evidence that MAC is necessary. The medical condition must be significant enough to impact the need to provide MAC, such as the patient being on medication or being symptomatic, etc. The presence of a stable, treated condition of itself is not necessarily sufficient.

The following quote is from Guidelines for the use of deep sedation and anesthesia for GI endoscopy, Gastrointestinal Endoscopy, Volume 56, No. 5, 2002, p. 616. "The routine assistance of an anesthesiologist for average risk patients undergoing standard upper and lower endoscopic procedures is not warranted and is cost prohibitive." This position of the gastrointestinal endoscopy community justifies this LMRP/LCD's position that, to allow payment, MAC for these procedures must be justified by the presence of one of the listed conditions.

Moderate (Conscious) Sedation 

Anesthesia services range in complexity. The continuum of anesthesia services, from least intense to most intense in complexity is as follows: local or topical anesthesia, moderate (conscious) sedation, regional anesthesia and general anesthesia. Prior to 2006, Medicare did not recognize separate payment if the same physician provided the medical or surgical procedure and the anesthesia needed for the procedure.

Moderate sedation is a drug induced depression of consciousness during which the patient responds purposefully to verbal commands, either alone or accompanied by light tactile stimulation. Moderate sedation does not include minimal sedation, deep sedation or monitored anesthesia care. In 2006, the CPT added new codes 99143 to 99150 for moderate or conscious sedation. The moderate (conscious) sedation codes are carrier priced under the Medicare physician fee schedule.

CPT codes 99143 to 99145 describe moderate sedation provided by the same physician performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient’s level of consciousness and physiological status. The physician can bill the conscious sedation codes 99143 to 99145 as long as the procedure with it is billed is not listed in Appendix G of CPT. CPT codes 99148 to 99150 describe moderate sedation provided by a physician other than the health care professional performing the diagnostic or therapeutic service that the sedation supports.

The CPT includes Appendix G, Summary of CPT Codes That Include Moderate (Conscious) Sedation. This appendix lists those procedures for which moderate (conscious) sedation is an inherent part of the procedure itself. CPT coding guidelines instruct practices not to report CPT codes 99143 to 99145 in conjunction with codes listed in Appendix G. The National Correct Coding Initiative has established edits that bundle CPT codes 99143 and 99144 into the procedures listed in Appendix G.

In the unusual event when a second physician other than the health care professional performing the diagnostic or therapeutic services provides moderate sedation in the facility setting for the procedures listed in Appendix G, the second physician can bill 99148 to 99150. The term, facility, includes those places of service listed in Chapter 23 Addendum field 29. However, when these services are performed by the second physician in the nonfacility setting, CPT codes 99148 to 99150 are not to be reported.

If the anesthesiologist or CRNA provides anesthesia for diagnostic or therapeutic nerve blocks or injections and a different provider performs the block or injection, then the anesthesiologist or CRNA may report the anesthesia service using CPT code 01991. The service must meet the criteria for monitored anesthesia care. If the anesthesiologist or CRNA provides both the anesthesia service and the block or injection, then the anesthesiologist or CRNA may report the anesthesia service using the conscious sedation code and the injection or block. However, the anesthesia service must meet the requirements for conscious sedation and if a lower level complexity anesthesia service is provided, then the conscious sedation code should not be reported.

If the physician performing the medical or surgical procedure also provides a level of anesthesia lower in intensity than moderate or conscious sedation, such as a local or topical anesthesia, then the conscious sedation code should not be reported and no payment should be allowed by the carrier. There is no CPT code for the performance of local anesthesia and as payment for this service is considered in the payment for the underlying medical or surgical service.

Mutually Exclusive Procedure Code edits

Mutually Exclusive Procedures are procedures that cannot be reasonably done in the same session.

To be consistent with existing payment policy, when Mutually Exclusive procedures are billed for the same date of service, only the procedure with the highest relative value ("When Billed with Procedure") will be allowed and the procedure with the lower relative value ("Deny Procedure") will be denied as Mutually Exclusive of the other procedure.

In some situations, according to CMS, certain modifiers may be allowed to bypass these edits.


Deny Procedure           When Billed with Procedure

00740                             43239

Unusual Anesthesia

Claims for this level should be billed using codes 00740 or 00810 with modifier 23 describing unusual anesthesia when performed only in an inpatient, outpatient or ASC setting. BCBSKS will only reimburse CRNAs or a physician capable of starting anesthesia. Reimbursement will be the provider's charge up to a maximum of $307.50.


Monitored Anesthesia

BCBSKS will make payment to an anesthesiologist or CRNA for monitored anesthesia in those limited situations where the patient’s condition is considered “at risk” and the use of monitored anesthesia care or general anesthesia is required to adequately and safely perform the procedure. If you have a patient who meets one of the criteria listed below and receives monitored or general anesthesia, you will need to bill the appropriate CPT anesthesia code (00740, 00810, 01920, or 01922) and ICD-9 diagnosis codes or modifiers that areindicated below. When monitored anesthesia care is performed, modifier QS should always be reported in addition to the CPT anesthesia code along with the appropriate diagnosis codes. These situations will be reimbursed using standard anesthesia reimbursement methodology. indicated below. When monitored anesthesia care is performed, modifier QS should always be reported in addition to the CPT anesthesia code along with the appropriate diagnosis codes. These situations will be reimbursed using standard anesthesia reimbursement methodology.


(1) Anesthesia Services Furnished in Conjunction With Lower Gastrointestinal (GI) Procedures (CPT Codes 00740 and 00810)

CPT codes 00740 and 00810 are used to report anesthesia furnished in conjunction with lower gastrointestinal (GI) procedures. In the CY 2016 PFS  proposed rule (80 FR 41686), we discussed that in reviewing Medicare claims data, a separate anesthesia service is typically reported more than 50 percent of the time that various colonoscopy procedures are reported.

We discussed that given the significant change in the relative frequency with which anesthesia codes are reported with colonoscopy services, we believed the relative values of the anesthesia services should be reexamined. We proposed to identify CPT codes 00740 and 00810 as potentially misvalued andsought public comment regarding  valuation for these services.

The RUC recommended maintaining the base unit value of 5 as an interim base value for both CPT code 00740 and 00810 on an interim basis, due to their concerns about the specialty societies’ surveys. The RUC suggested that the typical patient vignettes used in the surveys for both CPT codes 00740 and 00810 were not representative of current typical practice and recommended that the codes be resurveyed with updatedvignettes. We stated in the CY 2017  proposed rule that we believed it
premature to propose any changes to the valuation of CPT codes 00740 and 00810, continued to believe that these services are potentially misvalued, and sought additional input from stakeholders for consideration during future rulemaking.


Comment: Commenters were supportive of CMS’ proposal to maintain the current values for CPT codes 00740 and 00810 for CY 2017. One commenter requested that CMS ensure that reimbursement for anesthesia services remains adequate to compensate providers for the cost of furnishing these services. Commenters also stated that due to greater complexity of furnishing anesthesia services compared to moderate sedation, payment for anesthesia services should not be lower than the values established for moderate sedation.

One commenter stated that CMS’ perception that these codes are misvalued is related to the distinction between screening, diagnostic, and therapeutic endoscopies. Thecommenter further stated that there are no differences in the clinical risk and anesthesia preparation regardless of the indication for these procedures and suggested that the current base unit value of 5 units for CPT codes 00740 and 00810 is appropriate and should be maintained. Another commenter stated that the frequency of use of separate anesthesia services concurrent with colonoscopy procedures is not due to any potential misvaluation, but rather due to changes in Medicare coverage and payment policies that encourage Medicare beneficiaries to undergo screening colonoscopies.


Response: We appreciate the information provided by commenters. We continue to encourage feedback from interested parties and specialty societies, all of which we will take under consideration for future rulemaking.

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