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Anesthesia for Endoscopies – Get Paid!

If you’ve spent any time in anesthesia billing you’ll have learned that some payers consider anesthesia for endoscopy medically unnecessary.  It seems that list of payers grows every day.  It is important to understand that the payers aren’t denying the endoscopy procedure itself for medical necessity, but the anesthesia for the endoscopy.  The rationale behind these policies is that the gastroenterologist, in most cases, can provide adequate sedation for the patient during the procedure, thereby negating the need for anesthesia professionals to be present. 

Unfortunately, it doesn’t always work that way in the real world.  Many hospitals have policies and standards of care that require the presence of an anesthesia professional.  Moreover, some patients present with a higher risk than others.  So what should you do if you’re providing anesthesia for endoscopic procedures?  The answer to that question is simple: document all underlying conditions, know the payers’ policies, and put an ABN/waiver policy into place.

Documentation of all underlying conditions is vital to getting endoscopy procedures reimbursed properly.  Conditions such as diabetes, heart failure, COPD, hypertension, morbid obesity and PVD are just a few that may qualify your patient for anesthesia.  It is important to review the patient’s medical history thoroughly and document any of these conditions clearly in the pre-anesthetic evaluation.  Conditions or anomalies that could potentially cause difficulty with intubation should be documented as well.  For patients who have an ASA physical status of 3 or more, providers should document the conditions which elevate the physical status in addition to documenting the status.   

Understanding the payers’ policies is also an important element in being reimbursed.  Some payers set limitations on underlying diagnoses such as hypertension (401.9).  For example, the Novitas LCD L32628 specifically states “Use of the diagnosis code 401.9 must be representative of the patient’s condition (systolic pressure over 180 or diastolic over 110 and on more than two antihypertensive medications.)”  Some payers have very specific lists of criteria for anesthesia for endoscopy and some have less specific guidelines.  Whatever the case, it is always a good practice to know your payers’ policies.

Unfortunately, there will be plenty of patients who do not meet payer criteria for anesthesia for endoscopy.  In this case the best course of action is to inform the patient up front that his/her insurance may not cover the cost of anesthesia and get a signed ABN (advanced beneficiary notice) or waiver stating the patient’s responsibility for non-covered charges.   Many payers, particularly Medicare, do not allow you to bill the patient unless you inform them in advance that the procedure may not be covered.  An ABN or waiver may be your only recourse if a procedure is denied for medical necessity.

Getting paid for providing anesthesia services for endoscopy procedures gets harder every day, but it doesn’t have to be impossible.  If you document underlying conditions, know your payers’ policies and put an ABN/waiver policy into effect, you can be very successful at obtaining maximum reimbursement for your services.

Heather E. Golfos, CPC, Coding Department Assistant Manager

On Friday, May 3, 2013

Categories: Compliance & Coding News

The information presented herein reflects general information that is current as of the date it was first published. Please check with your individual legal and/or compliance advisor(s) prior to taking any significant actions based upon the information and advice presented.

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