No CRNA reimbursement for scopes??

allnurses Guide · Oct 20, 2011

Insurance companies will not usually provide reimbursement for conscious sedation. IMO you shouldn't be doing routine sedation on healthy patients for GI procedures in the hospital. That is something that can be done easily by an RN with a little training. It is waste of time and resources for CRNAs to be doing the sedation on these healthy patients.

We only do GI sedation on sick patients or patients that have proven track record of being hard to sedate.

subee, MSN, CRNA · Oct 20, 2011

I think the OP is an RN, not CRNA. An RN in the endoscopy suite is already being paid by the hospital and conscious sedation is part of the job. Am I missing something here? Insurance companies don't pay a separate fee for conscious sedation, nor should they.

mw2150 · Oct 21, 2011

I am a solo CRNA in a small critical access hospital with one OR. We don't have an endoscopy suite and many of the RNs and doctors for that matter at my facility are not comfortable with 'conscious sedation' so anything sedation-related is turfed to me (ER, GI, procedures, etc.). I have been working on training them to get them more comfortable but it is taking time.

I know that there is typically a facility charge and a separate physician charge on scopes. If an RN completes the sedation, is that charge usually included in the facility charge or can the hospital bill separately for 'RN conscious sedation' or is there no reimbursement whatsoever for any type of sedation (RN, CRNA, or MD) on ASA 1 or 2 patients? When I worked in bigger hospitals, we also only did scopes on sick patients or those deemed difficult to sedate.

The gastroenterologist prefers to have a CRNA on all of his GI cases and prefers propofol sedation for many different reasons - quicker room turnaround, quicker recovery times, less nausea, patient comfort, etc. Administration wants me in on all scope cases to keep the doctor and patients happy, regardless of whether or not we are reimbursed. I just wanted to see if it was possible to get any reimbursement for my services, even if it is billed as an RN. Because right now we're not getting anything.

Thanks again in advance.

Home Health Columnist / Guide · Oct 22, 2011

sedation and anesthesia in gi endoscopy

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billing diagnosis & billing in endoscopy

BCRNA · Oct 26, 2011

No, in my experience there is no way to bill for ANY anesthesia services in healthy patients for special procedures. We aren't really needed. Con. Sedation by an RN is not any slower in turnaround, though I bet it takes longer for patients to recover. There are modifiers that can be used to make ASA 1 and 2 patients eligible for anesthesia services: history of difficult sedation, abnormal airway, etc.

I have to wonder though, what is a gastroenterologist doing at a facility with no special procedures suite? That's like a cardiologist with no cath. lab. He shouldn't expect to be able to routinely do procedures at a hospital with no place to do them.

loveanesthesia · Nov 2, 2011

I was hoping that some CRNAs or SRNAs can provide me some insight on a very important topic. I know that this isn't a new thing, but I just found out that Medicare will not reimburse for anesthesia/sedation for colonoscopies or EGDs for ASA 1 or 2 patients - only ASA 3 and above. Since many of the commercial insurances attempt to mirror Medicare, many of the major commercial players will not reimburse for ASA 1 or 2 patients either.
I have a good friend who is a CRNA who works full-time in a very busy outpatient endoscopy center and I asked him what they did and he said that they do a ton of scopes every day on majority ASA 1 and 2 patients. He said that because they are able to turn the rooms over so quickly using propofol, that the sheer volume of patients they do every year more than makes up for not getting reimbursed for anesthesia services, so they just end up eating the anesthesia cost.
Since we are not doing hundreds of scopes a month, what are you CRNAs doing for EGD and colonoscopy billing, especially those of you in the hospital? I know that there may potentially be some instances in which commercial payers and Medicare may reimburse on ASA 1 and 2 patients - (difficult to sedate, sleep apnea, etc.) but even that is a pretty gray area. Do any of you know whether or not insurances reimburse for "RN conscious sedation"? I'm just tired of providing such a great, safe service to patients and not getting reimbursed for any of it. I would love to see the law makers and insurance company personnel get their scopes done with no sedation - I'm sure they would change their mind pretty quickly.
Thanks in advance for any help or insight.

Reimbursement is not tied to the ASA Physical Status but the physician conducting the procedure does need to justify why anesthesia is necessary in order for anesthesia to be reimbursed. We also have the patient sign a form indicating that if the anesthesia costs are not reimbursed then the patient is responsible for the costs. Inability to complete the exam because the patient does not cooperate is a reason. We require that the patient return another day so that we can do a proper workup and consent, rather than stepping in after the procedure was attempted with the RN doing the sedation. Sleep apnea, CHF are 2 reasons that are accepted as far as I know.

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ASA PS is not defined anywhere, so it can't be applied consistently. There are many studies documenting the variability in assigning a PS to the same patient. It is not used in billing.

allnurses Guide · Nov 2, 2011

Reimbursement is not tied to the ASA Physical Status but the physician conducting the procedure does need to justify why anesthesia is necessary in order for anesthesia to be reimbursed. We also have the patient sign a form indicating that if the anesthesia costs are not reimbursed then the patient is responsible for the costs. Inability to complete the exam because the patient does not cooperate is a reason. We require that the patient return another day so that we can do a proper workup and consent, rather than stepping in after the procedure was attempted with the RN doing the sedation. Sleep apnea, CHF are 2 reasons that are accepted as far as I know.
,
ASA PS is not defined anywhere, so it can't be applied consistently. There are many studies documenting the variability in assigning a PS to the same patient. It is not used in billing.

From Aetna (which seems to be consistent with other insurances/medicare from what I have read):

Clinical Policy Bulletin: Anesthesia Services for Gastrointestinal Endoscopy

Policy

Aetna considers moderate sedation/analgesia, provided by or under the direction of the endoscopist, to be appropriate and adequate for average risk individuals undergoing standard upper or lower endoscopic procedures. Consequently, Aetna considers not medically necessary the attendance of an anesthesiologist or anesthetist for average risk individuals undergoing standard upper or lower endoscopic procedures.

Aetna considers the use of general anesthesia, monitored anesthesia care (MAC) or deep sedation and the attendance of an anesthesiologist or anesthetist medically necessary for upper or lower gastrointestinal endoscopic procedures in individuals with any of the following sedation-related risk factors when requested by the attending physician:

I. Significant medical conditions:

American Society for Anesthesia Physical Status Class P3 to P5 (see appendix); or Pregnancy; or

Epilepsy; or

Children and adolescents (18 years of age or younger); or

Elderly persons (65 years of age or older).

II. Danger of airway compromise:

History of sleep apnea or stridor; or

Persons with dysmorphic facial features, such as Pierre-Robin syndrome or Down

syndrome; or

Persons with oral abnormalities, such as small opening (less than 3 cm in adult);

protruding incisors; high arched palate; macroglossia; tonsillar hypertrophy; or a non-

visible uvula; or

Persons with neck abnormalities, such as obesity involving the neck and facial structures,

short neck, limited neck extension, spinal cord instability, decreased hyoid-mental distance (less than 3 cm in adult), neck mass, cervical spine disease or trauma, disorders of cranial nerves IX or X, tracheal deviation, or advanced rheumatoid arthritis; or

Persons with jaw abnormalities, such as micrognathia, retrognathia, trismus, or significant malocclusion; or

Morbid obesity (BMI greater than 40 or BMI greater than 35 with comorbid medical conditions (refractory hypertension, obstructive sleep apnea, coronary heart disease, type 2 diabetes)).

III. Persons with anticipated intolerance of standard sedatives:

1

Persons with previous problems with anesthesia or sedation; or Dependence on opiates, sedatives, or hypnotics; or

Drug or alcohol abuse.

IV. Situations in which deep sedation or general anesthesia may be required:

Uncooperative or combative persons (e.g., persons with dementia, psychiatric disorders, young children, etc.); or

Complex procedures or invasive therapeutic procedures (e.g., endoscopic retrograde cholangiopancreatography (ERCP), endoscopic ultrasound (EUS), upper gastrointestinal stenting, emergency therapeutic procedures).