Wednesday, June 30, 2010

Anesthesia CPT - 00740, 00810 - gastrointestinal endoscopic procedures

Coding:

CPT Codes:

00740 Anesthesia for upper gastrointestinal endoscopic procedures, endoscope introduced proximal to duodenum

00810 Anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum.


Use of Anesthesia Services for Routine Gastrointestinal Endoscopy

As a general rule, benefits are payable under Blue Cross and Blue Shield of Alabama health
plans only in cases of medical necessity and only if services or supplies are not investigational,
provided the customer group contracts have such coverage.

The following Association Technology Evaluation Criteria must be met for a service/supply to be
considered for coverage:

1. The technology must have final approval from the appropriate government regulatory
bodies;
2. The scientific evidence must permit conclusions concerning the effect of the technology on
health outcomes;
3. The technology must improve the net health outcome;
4. The technology must be as beneficial as any established alternatives;
5. The improvement must be attainable outside the investigational setting.




Description of Procedure or Service:


Intravenous sedation and analgesia is routinely administered for gastrointestinal endoscopic examinations to help alleviate patient anxiety and discomfort. Provision of sedation and analgesia for endoscopy procedures is standard practice. In the United States, licensed registered nurse or  physician assistant administration of intravenous opiate narcotic, usually meperidine (Demerol®), in combination with a benzodiazepine, usually midazolam (Versed®), under the direct supervision of a licensed physician endoscopist is the traditional method for achieving sedation.

Recently propofol (Diprivan) has been used as an alternative method of sedation for patients undergoing endoscopy procedures. Propofol is a short-acting anesthetic agent. The advantages of propofol are its rapid induction of sedation, quicker patient recovery time, and anti-emetic effect. The use of propofol requires monitoring for respiratory and/or cardiac collapse by trained personnel.

usage with Modifier 

CPT modifier 76 – Repeat Procedure or Service by Same Physician The patient is returned to the operating room on the same day for the same or a related procedure. The same physician who is performing the repeat service should bill the repeat procedure with the 76 CPT modifi er.

ABC Medical Group 01/01/2013 00740 HCPCS Modifier AA-First Service

ABC Medical Group 01/01/2013 00810 HCPCS ModifierAA CPT Modifier 76-Repeat Service

CPT Modifier 77 – Repeat Procedure by Another Physician When a patient is taken back to surgery on the same day for the same or a related procedure by a different physician than the physician who performed the first service, submit the repeat procedure with the 77 CPT modifi er.

Example

Provider Date of Service CPT code Modifier

ABC Medical Group 01/01/2013 00740 HCPCS Modifi er AA-First Service

XYZ Medical Group 01/01/2013 00810 HCPCS ModifierAA CPT Modifier 77-Repeat Service

Services Paid at a Flat Fee 

The following procedures will be paid at a flat fee:

• Anesthesia for colonoscopy/upper GI endoscopy – Propofol (CPT Codes 00740 and 00810) at $250
• Physician Behavioral Health services (unless carved out in your agreement at different rates):

Evaluation and Management and Related Modifiers 25 and 57 Anthem recognizes that there may be a time when a patient presents for a routine physical examination and an abnormality or preexisting problem is encountered that requires a significant and separately identifiable evaluation and management (E/M) service as indicated by the addition of modifier 25.

There is duplication of the indirect practice expense when both a routine physical examination and a problem oriented E/M service are reported on the same date of service by the same provider. Therefore, for dates of service on or after July 1, 2015 when modifier 25 is reported with the problem-oriented or preventive E/M code for the same date of service by the same provider, the maximum allowance for the problem oriented E/M will reduced by 50%. The E/M and Related Modifiers 25 and 57 reimbursement policy will be updated to reflect this change effective July 1, 2015. [See Reimbursement Policy: E/M and Related Modifiers 25 and 57]

00740 Anesthesia for upper gastrointestinal endoscopic procedures, endoscope introduced proximal to duodenum


Average risk screening: Lack of symptoms and abnormalities

X Screening, by definition, is a service performed on a patient in the absence of signs and symptoms.

X Medicare’s definition of average risk is no personal history of adenomatous polyps, colorectal cancer or inflammatory bowel disease, including Crohn’s disease and ulcerative colitis; no family history of colorectal cancers or an adenomatous polyp, familial adenomatous polyposis, or hereditary nonpolyposis colorectal cancer.

X For most payors, a patient is eligible for screening colonoscopy on or after age 50. Some payors allow for screening to begin at age 45 for patients of certain gender and/or ethnic origin. If there are questions, check the summary of plan documents (SPD) and/or the plan’s coverage policies.

X Since Jan. 1, 2011, Medicare waives the co-pay and deductible for the professional and facility fees for screening colonoscopy at 100 percent with no patient financial responsibility.

X In the final rule for 2015, Medicare expanded the waiver of co-pay and deductible to include anesthesia for screening colonoscopy. A -33 modifier should be added to the 00810 anesthesia code to indicate the circumstance was preventive. This coverage “trumps” local contractor medical necessity policies now in existence in a screening circumstance. In the circumstance when a screening procedure becomes therapeutic (see next bullet), the PT modifier should be applied to the anesthesia service. A copay will still apply, but the deductible should be waived.

X If the screening colonoscopy is negative, a follow-up procedure is allowed every 10 years by Medicare. The frequency for follow-up for commercial payors is dependent upon the patient coverage/plan, but most follow either CMS policy or the U.S. Multi-Specialty Task Force (MSTF) recommendations.

X Billing for a screening colonoscopy in an average risk patient:

• Medicare: G0121

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