    
Final Comments Avail
Board Administrator
Username: Admin
Post Number: 68
Registered: 10-2002
| | Posted on Friday, September 26, 2008 - 10:09 am: | 
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Final Comments:
Moderate (Conscious) Sedation (AN- 030)
* Note; presented to CAC as Sedation and Analgesia by Non-anesthesiologists
Comment:
Several provider's found the name of the policy, *Sedation and Analgesia by Non- anesthesiologists arbitrary and confusing. They commented that a better name is "Moderate (Conscious) Sedation, CPT codes 99143 – 99150", as it is stated in the CPT Manual.
Response:
There is a National Coverage Provision entitled "Anesthesia Services."
However, we agree that the name is misleading. We will change it to Moderate (Conscious) Sedation and have agreement with the CPT Code Book section.
Comment:
A suggestion was made that for the purpose of improved clarity the following two sentences be deleted from the section entitled Second Physician (CPT codes 99148-99150)
Procedures not listed in Appendix G will ordinarily be performed without moderate sedation or under anesthesia described by CPT codes 00100-01999.
Since Medicare does not allow payment to a physician for services performed by a facility employee or any resident, the independent trained observer assisting in the monitoring of the patient's level of consciousness and physiological status of the patient cannot be any hospital employed personnel.
Response:
The first sentence has been deleted from the policy
The second sentence has been amended to state
Since Medicare does not allow payment to a physician for services performed by a facility employee or any resident, the independent trained observer assisting in the monitoring of the patient's level of consciousness and physiological status of the patient cannot be any hospital employed personnel.or resident.
Comment:
It is unclear how the policy is handling diagnostic vs. therapeutic procedures.
Response:
The third sentence under the sub-section entitled Limitations has been amended to state "Sedation/analgesia may be provided by the same physician performing the diagnostic or therapeutic procedure that the sedation supports, or by another physician."
Comment:
LCD is focused on moderate sedation. What impact does this LCD have on propofol?
Response:
The policy is not specific to any medication. If the use of propofol results in moderate sedation, then this LCD impacts on it.
Comment:
Is propofol moderate or deep sedation?
Response:
We expect that any practitioner who is using any medication to understand the medication and its effects. If the practitioner does not understand if a drug (or drugs) being used are minimal sedation, moderate sedation deep sedation, or general anesthesia, then the practitioner should not be doing the procedure.
Comment:
Does the draft affect deep sedation coverage? It also seems to exclude
coverage in offices, is that the intent?
Response:
The intent of this policy is to clarify billing and coding changes that resulted from the change in national Medicare policy. Until recently, a practitioner was not allowed to perform both a surgical procedure AND perform the anesthesia involved with it. This policy only excludes some office situations, but any exclusion is based solely on CPT Code Book instructions.
Comment:
This is a national issue. Did this draft originate somewhere else?
Response:
This draft is based on other carriers' drafts.
Comment:
Third paragraph under "Second Physician (CPT codes 99148-99150): Two comments with similar concern about paragraph that reads; "Moderate sedation is not medically necessary for procedures performed under local anesthesia or for peripheral nerve blocks" indicates that local anesthesia can't be used with moderate sedation and the sentence should be removed. In these circumstances supporting documentation would specifically describes the problem (eg. inadequate block, or the patient behavior) and be provided upon request.
Response:
This section has been removed.
Comment:
A suggestion was made for removal of the sentence under Limitations section that says "The practitioner must be certified in advanced cardiac life support."
Response:
This entire paragraph has been amended to state Because moderate conscious sedation may progress to deep sedation or general anesthesia, the availability of appropriate resuscitative personnel and equipment is required for patient safety. A suggested minimum includes a source of supplemental oxygen, suction source, airway support and pharmacologic antagonists. The practitioner should be appropriately trained in airway management and resuscitative skills.
Comment:
A national medical society whose members perform both surgery and administers general anesthesia or moderate sedation with his or her anesthesia team commented that they should be reimbursed for both if he/she has the requisite education, training and required state license and/or permits to perform these services.
Response:
The issue is not whether one's society feels a service should be paid. The issue is whether a service is allowed by national regulation or by federal law. In addition, we must abide by the definitions and/or restrictions that the CPT Code Book places on practitioners. In addition, all contractors must develop policies that protect beneficiaries.
Comment:
A national medical association states that exclusion of separate payment for CPT codes 99143-99145 and 99148-99150 may impede access of care. They therefore asked that there not be bundling edits for CPT codes 99143-99145 and 99148-99150
Response:
The requirement of bundling edits is a national regulation. All contractors must abide by national regulations.
Comment:
The allowed place of service for the two sets of CPT codes is confusing
Response:
The policy was amended to state under section entitled Same Physician (CPT codes 99143-99145); CPT codes 99143-99145 can be billed in either a facility or a non-facility setting. However, these services are covered and separately reimbursed ONLY when the procedures with which moderate sedation is performed are NOT listed in Appendix G of CPT code book.
The policy was also amended to state under section entitled Second Physician (CPT codes 99148-99150); the moderate sedation services of the second physician are not covered or reimbursed when performed in a non-facility setting. Medicare defines a facility as a hospital, outpatient hospital, ambulatory surgical center (ASC) or skilled nursing facility.
Comment:
Non-anesthesiologists is not used in the CPT Manual or in the CR/IOM, therefore, I think you'd have a hard time excluding anesthesiologists (and CRNAs) from the use of CPT codes 99143-45. I think that the following excerpt from the CR is pertinent to this:
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………\
I think that the above statement makes it impossible to exclude anesthesiologists, CRNAs (or nerve blocks) from the use of CPT codes 99143-45.
3. However, if a second physician is needed for Moderate (Conscious) Sedation, AND that second person is an anesthesiologist or CRNA, that second person would use an "0xxxx"/anesthesia code, as indicated from the example used in the following CR/IOM excerpt:
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 0199………….
This would apply either in the facility or non-facility setting as there are no POS limitations on the 0xxxx codes.
Response:
The coordination of services between an anesthesiologist or CRNA and/or any other provider must conform to national Medicare regulations and billing requirements.
Comment:
After having reviewed CPT and the specific codes, it seems inconsistent with CPT to specify any specific type of codes (i.e. nerve blocks) that are not already identified by Appendix G.
Response:
The codes addressed in this LCD pertain to moderate conscious sedation.
Comment:
A few spelling and grammar errors were reported.
Response:
Spelling and grammar errors have been corrected.
Comment:
It is inappropriate that only anesthesiologists' guidelines are cited, despite the fact that the GI societies have separately addressed this topic and one could fairly argue GI would be better able to comment on how to sedate for GI procedures.
Response:
The focus of this LCD is to provide useful information concerning the use of CPT codes 99143-99150 designated for moderate, conscious sedation.
Comment:
If G codes are used then sedation is inherent, if not it is covered separately. Similarly it appears to cover when a second physician for therapeutic but not diagnostic procedures This, despite the fact that screening and diagnostic colonoscopies are the same procedure, albeit for different indications. If the intent of CMS is not to allow duplication of payment (e.g. additional payment for services considered inherent in the procedure), G codes should also be affected.
Response:
At this time federal regulations have determined the RVUs for either screening colonoscopies or diagnostic colonoscopies to be the same. (FR 1997, Volume 62, Number (211)). However, this LCD does not address the G codes assigned for screening endoscopy procedures. For further information related to colonoscopies refer to WPS LCD Diagnostic Sigmoidoscopy and Colonoscopy (GI-006) and WPS NCD Colorectal Cancer Screening Benefits (GI-008).
Comment:
The draft policy exhibits the same confusing dichotomy when a second physician (e.g. an anesthesiologist) is used. The policy proposes to separately reimburse for the second physician for sedation but only for those used to support services listed in Appendix G in a facility setting, e.g. screening colonoscopy, but not for diagnostic and therapeutic endoscopic procedures.
Response:
The American Medical Association owns the CPT codes and only they can change the definitions of them.
Comment:
The draft appears to exclude from coverage payment for a second physician for moderation sedation when the procedure is performed in an office setting. While most endoscopy services are performed in a facility setting, not all are, particularly in certain parts of the country where Certificate-of-Need restrictions have generally precluded or restricted the development of endoscopy centers. We are therefore concerned about the national precedent that this exclusion could create.
Response:
The American Medical Association owns the CPT codes and only they can change the definitions of them. If one has concerns about the CPT Code Book or definitions of any CPT codes, please contact the American Medical Association. Until the definitions and/or the codes change, we must abide by their definitions.
Comment:
Under "Sources of Information and Basis for Decision," we observe that anesthesia guidelines are cited, but not other society guidelines. In 2004, the ACG, along with our sister gastroenterology societies, the American Society for Gastrointestinal Endoscopy (ASGE) and the American Gastroenterological Association (AGA), issued a joint statement on the use of sedation in endoscopy. That statement reports that endoscopic procedures including colonoscopy are successfully performed with moderate (conscious) sedation and that compared to standard doses of benzodiazepines and narcotics, propofol may provide faster onset and deeper sedation and recognizes that the use of propofol in endoscopy is a complex topic, both medically and scientifically. The statement also found that there are ample data to support the use of propofol by adequately trained non-anesthesiologists.
Response:
We have received and reviewed the above guidelines. However, the AGA/ASGE Guidelines deal with specific drug issues. This policy does not limit, endorse, or restrict any medications. The choice of agents is left to the practitioners. Their guidelines are completely in agreement with the draft policy. |
