Anesthesia Business Consultants Responds to Confusion over Anesthesia for Gastrointestinal Endoscopies
Anesthesia Business Consultants (ABC) is seeing more and more anesthesia bills come under scrutiny as payers tighten up on the issue of “medical necessity.” The medical necessity for general or regional anesthesia for most surgical procedures involving an incision is clear and universally recognized. For other, “non-invasive” procedures such as upper and lower gastrointestinal endoscopies, all that may be needed—or allowed by the payer—is “conscious” or “moderate” sedation. The difference is more than semantic: the cost of an anesthesiologist or nurse anesthetist providing anesthesia is considerably greater than the cost for the endoscopist to sedate the patient himself or herself while performing the endoscopy.
Payers vary in their criteria for deciding whether to allow anesthesia for routine endoscopies in typically healthy patients. Most payers have adopted specific medical necessity policies that spell out in detail the underlying patient conditions (e.g. extreme age, severe liver or heart disease, pregnancy, history of substance abuse) that will justify anesthesia. These policies are updated periodically and often without notice. It is very important, therefore, for physicians and their staff (and their billing companies) to keep up-to-date copies and to know what is in the policies covering the practice's patients. With that knowledge, they will understand not just when a patient is considered healthy enough to undergo endoscopy with sedation, but how they should document any condition that would support general anesthesia.
Another factor in choosing between “anesthesia” and “sedation” is the type of facility in which the endoscopy is performed. The numbers of freestanding endoscopy centers and private physicians' offices offering endoscopy are growing rapidly. In some states, notably in the Northeast and California, statutes or regulations require facilities to be accredited by a recognized agency in order to perform endoscopies or other ambulatory procedures—and to administer general anesthesia. Even in those states that do not require accreditation, if an endoscopy results in complications and it turns out that the facility had not obtained accreditation voluntarily, defending any malpractice lawsuit will be harder—for the facility and for the doctors involved, including the anesthesiologist, if any.
This is an evolving area, and ABC urges providers to familiarize themselves with the rules governing where and for whom anesthesia may be provided.
About Anesthesia Business Consultants
ABC, established in 1979, is the nation's largest billing and practice management company dedicated to the complex and intricate specialty of anesthesia and pain management. It is an Anesthesia Quality Institute Preferred Vendor. It has also successfully completed a Service Organization Controls (SOC) 1 Report, which is an independent third-party verification of a company's internal operational controls and processes. ABC employs industry leaders, operates under proven efficient processes, and utilizes technological advances to easily adapt to the ever-changing regulatory environment. Visit ABC at: www.anesthesiallc.com.
Anesthesia Business Consultants
Tony Mira, 517-787-6440