Services That Include Conscious Sedation: A Growing Denial Problem

-->December 20, 2016Magazine

    By: Matthew Harrison, RHIA, CPC, Chief Compliance Officer

    Medical necessity for procedures commonly performed under monitored anesthesia care (MAC) continues to be a problem – though some may be impacted more than others. Medac has published alerts and answered individual questions on this topic numerous times. This article serves to consolidate the key points of this issue. What you need to know before continuing:

    • This is a real problem
    • It does not apply to every case
    • It will impact some groups more than others, based on region and payer mix
    • It is critical to know the payer policies that impact your cases
    • If you do not have a covered diagnosis or pre-set payment arrangement, you will not be paid for services that fall under this issue

    Which Procedures are Impacted and Why?

    CPT coding guidelines list a number of procedures that are expected to be performed under moderate sedation (the surgeon’s payment includes an allowance for sedation). Therefore, separate anesthesia services by an anesthesia provider are generally not covered unless there is a medical reason for the deeper level of sedation/monitoring. These procedures include:

    • GI Colonoscopy and EGD procedures
    • Pain management procedures
    • Breast procedures
    • Skin procedures
    • Pacemaker implantations
    • Cataract procedures
    • Port placements

    For many of the breast, skin, and port placement procedures, we are able to tell the payer the procedure is deep or complex enough to require additional sedation. However, we are seeing high rates of denials in GI, pain management, and pacemaker procedures (again, denials are regional/payer based).

    What are Coverage Policies (i.e., MAC Anesthesia Policies)?

    Many – but not all – government, commercial, and national payers limit coverage of anesthesia to only those patients with a documented medical need for the deeper level of sedation. The most common policy is a Medicare LCD which defines specific diagnoses required when targeting specific surgical or MAC anesthesia services. Medicare’s policies typically include specific covered diagnoses, but most other payers simply state that anesthesia is not covered for a normal, healthy patient – leaving the covered conditions up to a medical review board, which may not be involved until denials have been appealed.

    Historically, common diagnoses such as anxiety, HTN, or obesity would often bypass these edits. Also, billing cases under General anesthesia instead of MAC anesthesia (as is often the case when Propofol is used) historically bypassed the edits. Neither is true in most cases today. Most payers are applying these policies to any item billed under a separate claim for anesthesia services.

    Anxiety, HTN, morbid obesity, and drug use, among others, remain valid diagnoses to bypass edits for most carriers, but payers have imposed strict criteria on when they can be used. For instance, “morbid obesity” requires a weight of at least 2x ideal body weight (BMI of 40 or above); “drug use” requires an acute detoxification state; “anxiety” requires an acute panic attack requiring sedation; and “HTN” requires systolic pressure over 180 or diastolic over 110 at the time of the procedure and prescribed more than two antihypertensive medications. In most routine scenarios, the procedure would never be performed under these conditions.

    Bottom Line: Many payers will not cover anesthesia on these cases for a normal, healthy patient.

    What about the ACA Legislation?

    Although the Affordable Care Act seemed to have expanded payer coverage for GI endoscopy services, you need to read between the lines. The ACA simply reduced Medicare patients’ coinsurance for screening colonoscopies, and does not impact private insurance plans in effect prior to the ACA legislation being passed (known as “grandfathered plans”). Also important to note is that the ACA does not affect non-screening colonoscopy procedures or EGD procedures.

    What Can I Do About It?

    There are a few options available to address this issue:

    • Documentation: It is critical to include mention of a patient’s comorbidities within the original anesthesia documentation. We have had success in appealing denials, but obtaining the necessary clinical information for an appeal leads to significant delays. Make sure that Medac is receiving a copy of your pre-anesthesia assessment (along with your anesthesia record) to glean valuable co-morbidity and underlying condition information for anesthesia billing services. The STOPBANG airway apnea questionnaire is also beneficial to incorporate into your patient’s pre-procedure paperwork to help support medical necessity. Of note, approximately 55% of the cases we review for appeal do not contain adequate medical necessity to support payment.
    • Advanced Beneficiary Notice (ABN): This is a document served to the patient outlining his options for sedation, and informing him of the likelihood that his payer might not cover sedation by a separate anesthesia provider and he will be responsible for payment. It is imperative that this is delivered to and signed by the patient before the service. This obviously introduces many logistical challenges for an anesthesia provider, and any anesthesia billing services.
    • Renegotiate Stipends or Alternative Payment Methodologies: This is a more aggressive and longer term solution that may alleviate the need to worry about coverage policies. This option, however, involves potential risk areas that should be addressed with an attorney prior to formalizing any contracts.

    Next Steps
    Check with your practice manager to see if you are currently experiencing any denials for these services from your top payers, it could be due to discrepancies between MAC anesthesia and General anesthesia billing.