Thursday, June 24, 2010

Medical and Surgical Services Rendered in Addition to Anesthesia Procedures

ANESTHESIA SERVICES

Medical and Surgical Services Rendered in Addition to Anesthesia Procedures

Payment may be made under the fee schedule for specific medical and surgical services by the
anesthesiologist as long as these services are reasonable and medically necessary or provided
other rebundling provisions do not preclude separate payment. These services may be rendered
in conjunction with the anesthesia procedure to the patient or as single services (e.g., during the
day of or the day before the anesthesia service). These services include the insertion of a Swan-
Ganz catheter, the insertion of central venous pressure lines, emergency intubations, and critical
care visits.

Anesthesia Services Furnished by the Same Physician Providing the Medical and Surgical Service

Physicians who both perform and provide moderate sedation for medical/surgical services will
be paid for the conscious sedation consistent with CPT guidelines. However, physicians who
perform, and provide local or minimal sedation for these procedures will not be paid separately
for the sedation services.

The continuum of complexity in anesthesia services (from least intense to most intense) ranges
from 1) local or topical anesthesia, 2) moderate (conscious) sedation, 3) regional anesthesia, to 4)
general anesthesia. Moderate sedation is a drug induced depression of consciousness during
which patients respond purposefully to verbal commands, either alone or accompanied by light
tactile stimulation. It does not include minimal sedation, deep sedation or monitored anesthesia
care.

In the past, the Medicare Claims Processing Manual instructed contractors not to allow separate
payment for the anesthesia service performed by the same physician who furnishes the medical
or surgical services (for example, there is no separate payment allowed for a surgeon’s
performance of a local or surgical anesthesia if the surgeon also performs the surgical procedure;
or a psychiatrist’s performance of the anesthesia service associated with the electroconvulsive
therapy if the psychiatrist performs the electroconvulsive therapy).
Prior to 2006, Medicare did not recognize separate payment if the same physician both performed
the medical or surgical procedure and provided the anesthesia needed for the procedure. The
final physician fee schedule published in the Federal Register on November 21, 2005 included
newly created codes (99143 to 99150) for moderate (conscious) sedation, which the CPT added in
2006.

The revised policy, effective January 1, 2006 and implemented October 1, 2007 is: If the physician
performing the procedure also provides moderate sedation for the procedure, then payment may
be made for conscious sedation consistent with CPT guidelines; however, if the physician
performing the procedure provides local or minimal sedation for the procedure, then no separate
payment is made for the local or minimal sedation service.

Contractors will not allow payment for codes 99148-99150 if any of these codes are performed on
the same day with a medical/surgical service listed in Appendix G of CPT (Summary of CPT
Codes That Include Moderate (Conscious) Sedation) and the service is provided in a non-facility
setting. A facility is defined as one with a place of service code of 21, 22, 23, 24, 26, 31, 34, 41, 42,
51, 52, 53, 56, or 61.

Note: These codes have been assigned a status indicator of “C” under the Medicare physician
fee schedule designating that these services are carrier priced. CMS has not established
relative value units for these services.

Three of these codes (99143, 99144, and 99145) describe the scenario in which the same physician
performing the diagnostic or therapeutic procedure provides the moderate sedation, and an
independent trained observer’s presence is required to assist in the monitoring of the patient’s
level of consciousness and physiological status. The other three codes (99148, 99149, and 99150)
describe the scenario in which the moderate sedation is provided by a physician other than the
one performing the diagnostic or therapeutic procedure.

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