EMPIRE MEDICARE’S POLICY FOR ANESTHESIA AND GASTORINESTINAL ENDOSCOPY
Patients undergoing gastrointestinal endoscopy receive medications for anxiety, discomfort and anesthesia, as well as monitoring during the procedure.
00740 Anesthesia for upper gastrointestinal endoscopic procedures00810 Anesthesia for intestinal endoscopic procedures
HCFA’s National PolicyAnesthesia by the performing surgeon is not separately reimbursable to the surgeon.Indications and Limitations of Coverage and/or Medical Necessity
- Patients undergoing upper and lower gastrointestinal endoscopy frequently receive medication for sedation, relief of anxiety and discomfort. “General anesthesia or the presence of an anesthesiologist is rarely indicated except in special circumstances. The endoscopy team should be trained in cardiopulmonary resuscitation.” (Preparation of Patients for Gastrointestinal Endoscopy, Guidelines for Clinical Application, American Society Gastrointestinal Endoscopy, publication #1016).
- Administration of medication and monitoring of the patient are performed by the endoscopy team, and the presence of an anesthesiologist/anesthetist is medically unnecessary except in those rare instances when a patient has a pre-existing unstable medical condition. Patients on a respirator are not considered unstable just because of their dependence on a respirator; in fact these patients may be less in need of an anesthesiologist/anesthetist since their airway is protected and their respirations controlled.
- It would seem inappropriate for any patient so medically unstable as to require the presence of an anesthesiologist/anesthetist to undergo an endoscopic procedure in the office setting.
- Services by an anesthesiologist/anesthetist for administration of anesthesia for gastrointestinal endoscopy in the in-patient, out-patient or ambulatory facility setting, where the only indication for the presence of an anesthesiologist or anesthetist is compliance with hospital or ASC policy, are medically unnecessary and not eligible for Medicare Part B reimbursement.
- Anesthesia services provided as “standby” are covered as part of the facility charge and are reimbursable under the Part A facility charge to hospitals and under the Part B facility charge to ASCs. These services may not be billed to the beneficiary.
- Administration of anesthesia by the performing surgeon (endoscopist) is included in the reimbursement for the surgical procedure (endoscopy).
- Young children and pediatric patients may require the presence of an anesthesiologist/anesthetist for anesthesiology during endoscopy.
- Patients with severe, uncontrolled hypertension (diastolic BP of 110 or greater) at the time of the endoscopy, may require the presence of an anesthesiologist/anesthetist. It would, however seem inappropriate for any such patient with uncontrolled hypertension to undergo any endoscopic procedure except for gastrointestinal emergencies. Therefore, unless the blood pressure is in the range indicated, anesthesia by an anesthesiologist/anesthetist is not considered medically necessary.
- Patients with acute asthma, acute thyrotoxicosis, acute, inadequately treated adrenal insufficiency, or diabetic ketaoacidosis or coma may require the presence of an anesthesiologist/anesthetist if these conditions are active medical problems requiring treatment at the time of the endoscopy.
- The presence of an anesthesiologist/anesthetist may be required for patients with psychiatric diagnosis if their condition prevents them from cooperating with the endoscopist during the procedure (such as acute drug or alcohol intoxication, or acute confusional state) and for patients requiring unusual sedation or anesthesia.
- Patients with acute upper gastrointestinal hemorrhage may require intubation for protection of their airway when the bleeding is truly hemorrhagic or massive. For these patients, the presence of an anesthesiologist/anesthetist may be medically necessary. The conditions supporting medical necessity are presumed to be active medical problems at the time of the endoscopic procedure.