A single colonoscopy can generate more than one bill: a procedure claim, a sedation claim, and sometimes a separate anesthesia claim, plus a facility claim when the case is done at an ASC.
Gastroenterology practices are also navigating anesthesia staffing shortages, falling reimbursement and a phased-in change to how screening colonoscopies are billed when they convert to diagnostic.
Here are 10 things to know about anesthesia and sedation billing in GI:
1. A single GI encounter often produces multiple, separate claims. The procedure itself is coded from the technique used on each lesion, sedation is billed under its own code family when the endoscopist administers it, and a distinct anesthesia claim is filed when monitored anesthesia care or general anesthesia is used instead. When the case is done at an ASC, a facility claim joins the mix, according to A2Z Billings.
2. Endoscopist-directed sedation and anesthesia-directed care follow different billing rules. Moderate sedation reported by the endoscopist is billed on the same claim as the procedure, under the same provider. Monitored anesthesia care or general anesthesia is billed separately by the anesthesia provider, using anesthesia-specific codes and time units, A2Z Billings said.
3. Mismatched documentation between the GI and anesthesia claims is a common trigger for denials. When the two claims list different start or stop times, or a different procedure description, for the same date and patient, both claims can be flagged during adjudication even when the care itself was appropriate, according to A2Z Billings.
4. Multiple polypectomy techniques in one session each need their own code. When more than one polyp is removed using different methods, cold biopsy, cold snare, hot snare or EMR, each technique has to be coded against the specific lesion it was used on. National Correct Coding Initiative edits determine which technique combinations can be billed separately and which are bundled, per A2Z Billings.
5. Anesthesia staffing shortages are compounding the billing complexity. Traditional anesthesia staffing models built around fixed daily blocks don’t match the volatile case-arrival patterns typical of non-operating room anesthesia settings, Megan Friedman, DO, chair and medical director of Pacific Coast Anesthesia Consultants, told Becker’s. Additionally, shortages of anesthesiologists and CRNAs are limiting patient access to GI procedures while reimbursement hasn’t kept pace with rising costs, Seth Gross, MD, clinical chief of gastroenterology and hepatology at NYU Langone Health, told Becker’s.
6. Colonoscopy demand has outpaced anesthesia capacity. The 2021 change lowering the recommended screening age to 45 added 19 million eligible patients, contributing to rising case volume alongside an aging workforce and growing patient preference for propofol sedation, Benjamin Levy, MD, a gastroenterologist at University of Chicago Medicine, told Becker’s.
7. Anesthesia is becoming a larger share of ASC overhead. The share of ASCs paying anesthesia stipends to secure coverage rose from 28% to 44% in a single year, even as procedure reimbursement has declined.
8. Medicare reimbursement for colonoscopy has been falling for years. ASC-based GI endoscopy services face an average 8% Medicare cut in 2026. Inflation-adjusted Medicare payments for colonoscopies fell more than 22% between 2018 and 2023, and reimbursement for colonoscopy with biopsy has declined 38% over 15 years.
“Especially if the procedure is complex and prolonged, we are left with a situation where the reimbursement just about covers the overhead costs,” Curuchi Anand, MD, a gastroenterologist at UMass Memorial Medical Center, told Becker’s.
9. Site of service creates a sizable payment gap. The average colonoscopy costs $1,136 in an ASC compared with $1,608 in a hospital outpatient department. For a practice performing 900 colonoscopies a year, that gap can translate into tens of thousands of dollars in payment difference depending on where cases are billed.
10. Screening-to-diagnostic conversions follow a phased cost-sharing schedule. When a screening colonoscopy becomes diagnostic after a polyp is found and removed, Medicare beneficiary coinsurance is being phased out under a schedule finalized in the 2022 Physician Fee Schedule: 15% from 2023 through 2026, 10% from 2027 through 2029, and eliminated entirely starting in 2030. The deductible is waived throughout. The coding mechanics behind screening-to-diagnostic conversions, including the 59/XS distinct-procedure modifier, are outlined by A2Z Billings.
At the Becker’s 32nd Annual Meeting: The Business and Operations of ASCs, taking place October 29-31 in Chicago, ASC leaders, surgeons and healthcare executives will explore strategies to drive growth, enhance operational performance, navigate reimbursement challenges and prepare for the future of ambulatory surgery. Apply for complimentary registration now.
