Anesthesia for GI Endoscopy: An Ongoing Problem of "Medical Necessity"

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The following article was written by Tony Mira, president and CEO of Anesthesia Business Consultants.

Gastrointestinal endoscopy is one of the safest and most commonly performed adult procedures. The record of safety extends to the sedation or anesthesia for both upper and lower GI endoscopy. Because of both the safety and the frequency of the procedure, anesthesia for GI endoscopy has been under scrutiny by health plans for a decade or more.  Lately, the number of claims denied for lack of “medical necessity” for endoscopic anesthesia services have once again been growing. Without taking any position on the merits of anesthesia vs. moderate sedation in connection with endoscopies and especially colonoscopies, we would like to remind our audience of the principles followed by payers in evaluating the medical necessity of anesthesia for these procedures.

The differences between anesthesia and moderate sedation
Moderate sedation (aka "conscious sedation") is a "drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained." ASA Statement on Continuum of Depth of Sedation: Definition of General Anesthesia and Levels of Sedation/Analgesia (2009)

Although it is part of the continuum, moderate sedation is distinct from:

Deep Sedation/Analgesia — "a drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully** following repeated or painful stimulation. The ability to independently maintain ventilatory function may be impaired. Patients may require assistance in maintaining a patent airway, and spontaneous ventilation may be inadequate. Cardiovascular function is usually maintained,"

and from

General Anesthesia — "a drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation. The ability to independently maintain ventilatory function is often impaired. Patients often require assistance in maintaining a patent airway, and positive pressure ventilation may be required because of depressed spontaneous ventilation or drug-induced depression of neuromuscular function. Cardiovascular function may be impaired."

Because deep sedation may readily transition to general anesthesia, it is the position of ASA and of CMS that only a practitioner privileged to provide anesthesia services should be allowed to manage the sedation. The skills of an anesthesia provider are necessary to manage the effects of general anesthesia on the patient as well as to return the patient quickly to a state of "deep" or lesser sedation. ASA Statement on Distinguishing Monitored Anesthesia Care (“Mac”) from Moderate Sedation/Analgesia (Conscious Sedation)(2009).

Payment for moderate sedation differs from payment for anesthesia. 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. 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. Payment is priced by the individual Medicare contractor.

Anesthesia services, in contrast, are identified by codes 00100-01999 and are always provided by an independent anesthesia professional who is credentialed for that purpose by both the facility and by the payer. The payment calculation is based on the ASA Relative Value Guide base plus time unit system.

Consequence of the distinction for GI endoscopy procedures

"For routine endoscopic procedures and screenings among patients without risk factors or significant medical conditions, moderate sedation is considered a sufficient level of sedation." This is the basic principle, taken from Wellmark's Medical Policy on Anesthesia Services for Gastrointestinal Endoscopic Procedures.

In order for anesthesia to be considered medically necessary, the medical record should demonstrate specific patient risk factors.  Sedation-related risk factors include:

- Significant medical conditions, such as:
  • Extremes of age,
  • Severe pulmonary, cardiac, renal, or hepatic disease,
  • Pregnancy
  • Drug or alcohol abuse
- Uncooperative patients
- Potentially difficult airway for intubation
  • Patients with a history of stridor, snoring, or sleep apnea
  • Patients with dysmorphic facial features, such as Pierre-Robin syndrome or trisomy-21
  • Patients with oral abnormalities, such as small opening (less than 3 cm in adults), edentulous, protruding incisors, loose or capped teeth, high arched palate, macroglossia, tonsillar hypertrophy, or non-visible uvula;
  • Patients with neck abnormalities, such as obesity involving the neck and facial structures, short neck, limited neck extension, decreased hyoid-mental distance (less than 3 cm in adults), neck mass, cervical spine disease or trauma, tracheal deviation, or advanced rheumatoid arthritis
  • Patients with jaw abnormalities, such as micrognathia, retrognathia, trismus, or significant malocclusion.
- Patients with previous problems with anesthesia or sedation.

The patient conditions or comorbidities that will make anesthesia medically necessary are usually identified in the payers' medical policies by ICD-9 diagnosis code. Note that these conditions relate to anesthesia and are quite distinct from the signs, symptoms or even diagnoses that establish the medical necessity for the GI endoscopy itself. A typical policy will contain lists of ICD-codes covering multiple pages (e.g., Aetna).  Empire Blue Cross does not enumerate acceptable diagnosis codes but instead states in its policy that "anesthesia services including monitored anesthesia care (MAC) are considered medically necessary during gastrointestinal endoscopic procedures when there is documentation by the operating physician and the anesthesiologist that demonstrates any of the following higher risk situations exist:

- Prolonged or therapeutic endoscopic procedure requiring deep sedation; or
- A history of or anticipated intolerance to standard sedatives (e.g., individual on chronic narcotics or benzodiazepines, or has a neuropsychiatric disorder); or
- Increased risk for complication due to severe comorbidity (American Society of Anesthesiologists [ASA] class III physical status or greater. See Appendix for physical status classifications); or
- Individuals over 70; or
- Individuals under the age of 18; or
- Pregnancy; or
- History of drug or alcohol abuse; or
- Uncooperative or acutely agitated individuals (e.g., delirium, organic brain disease, senile dementia); or
- Increased risk for airway obstruction due to anatomic variant including any of the following:
  • History of previous problems with anesthesia or sedation; or
  • History of stridor or sleep apnea; or
  • Dysmorphic facial features, such as Pierre-Robin syndrome or trisomy-21; or
  • Presence of oral abnormalities including but not limited to a small oral opening (less than 3 cm in an adult), high arched palate, macroglossia, tonsillar hypertrophy, or a non-visible uvula (not visible when tongue is protruded with individual in sitting position e.g., Mallampati class greater than II); or
  • Neck abnormalities including but not limited to short neck, obesity involving the neck and facial structures, limited neck extension, decreased hyoid-mental distance (less than 3 cm in an adult), neck mass, cervical spine disease or trauma, tracheal deviation, or advanced rheumatoid arthritis; or
  • Jaw abnormalities including but not limited to micrognathia, retrognathia, trismus, or significant malocclusion

Note that the Empire policy calls for documentation of the patient risk by both the gastroenterologist and the anesthesiologist. Physicians should be familiar with the anesthesia policies — and specifically the policies pertaining to GI endoscopy — of the health plans to which their patients belong. There are differences, and only by furnishing the documentation specified by the policies can physicians make sure that they will satisfy applicable medical necessity requirements.

Is the facility accredited for anesthesia?


As the number of standalone endoscopy and office-based surgical suites has grown, it has become more common for anesthesiologists to administer anesthesia or deep sedation (almost always using propofol) in these facilities—which may not be accredited for the use of general anesthesia.

The lack of facility accreditation may not affect the anesthesiologist's payment, because few payers have systems that will compare the professional and the facility charges and require that they agree with each other, but it is nevertheless of concern. Accreditation is first and foremost a safety issue and it is the primary responsibility of the facility. Poor outcomes or untoward events occurring in the course of an anesthesia service provided in an unaccredited facility may be harder to defend in malpractice litigation.

Not every state or every health plan mandates the use of facilities certified by The Joint Commission, the Accreditation Association for Ambulatory Health Care or the American Association for Accreditation of Ambulatory Surgery Facilities, the major accrediting organizations. That is changing, however. In 2007, New York passed legislation requiring all office-based surgery practices that perform surgical or invasive procedures using sedation or general anesthesia obtain and maintain full accreditation status with a nationally recognized accrediting agency.   New Jersey, Massachusetts and California are among the states in which comparable initiatives have been undertaken. (Shapiro F, Urman D: Office-Based Anesthesia and Surgery: Creating a Culture of Safety. (2011)). The Institute for Safety in Office-Based Surgery, a new and important voice for patient safety, offers further information.

Both medical necessity requirements and the accreditation of the facility in which anesthesia services for GI endoscopy are subjects with which anesthesiologists should be familiar. We will be addressing them further in forthcoming issues of the Alert and of our quarterly Communique.

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