April 3, 2023

Is it just paranoia or are you really being picked on?  That’s what some anesthesia providers may be wondering when it comes to their attempted forays into gastrointestinal-related cases.  For some time now, it has become increasingly difficult to get paid in the GI context as a growing number of payers have been putting up roadblocks to reimbursement. 

A Growing Problem

Here’s a case in point.  Just recently, UnitedHealthcare (UHC)—which provides health insurance to approximately 45 million people worldwide—announced changes to its prior authorization rules for gastroenterology care that will take effect June 1.  Beginning on that date, UHC commercial plan patients will need to obtain prior authorization for gastroenterology endoscopy services, according to the insurance provider's website.  This has not gone down well with some in the GI industry.  Indeed, the American Gastroenterological Association (AGA) is asking its members to contact UHC and demand that these new prior authorization requirements be rescinded.  According to a report in Becker’s Payer Issues, “the AGA argues the burdensome new requirements will cause care delays for high-risk patients, deter patients from undergoing medically recommended procedures, exacerbate existing sociodemographic disparities in care and outcomes, and add unnecessary paperwork burden to physicians.”

Though screening colonoscopy procedures are not subject to the new prior authorization rule, the following GI procedures will require prior approval:

• Esophagogastroduodenoscopies
• Capsule endoscopies
• Diagnostic colonoscopies
• Surveillance colonoscopies

While this new policy does not make direct reference to anesthesia providers or anesthesia services, the net effect of this new UHC policy is the potential reduction of payable GI cases for both endoscopists and anesthesiologists.  Therefore, where possible, anesthesia providers will want to ensure that UHC patients have a prior authorization in place before providing these particular services.

But there are more direct pressures that have been placed on the anesthesia community as it pertains to GI procedures.  Over the last few years, many payers have put policies into place that tend to suppress the ability of the anesthesia practitioner to recover payment in GI cases.  It began with certain Medicare jurisdictions producing local coverage determinations (LCDs), now referred to as “medical policies,” that limited monitored anesthesia care (MAC) in GI cases to those patients who had certain co-morbidities or a physical status (PS) of III or higher.  When some providers got around these MAC policies by simply utilizing general anesthesia, some of these LCDs were revised to include that mode of anesthesia, as well.

It's not only certain Medicare facilities that have put the squeeze on anesthesia’s ability to get paid in these types of cases.  Commercial payers are following suit.  For example, we recently received a notification from BCBS of Massachusetts advising that a new anesthesia policy related to GI will go into effect on July 1 of this year.  It states in pertinent part:

Effective for dates of service on or after July 1, 2023, we will implement diagnosis-driven claim edits to reinforce our existing medical policy 154 [Monitored Anesthesia Care] guidelines.  In accordance with the above guidelines, endoscopic procedures can be performed under either moderate sedation or monitored anesthesia care.

Medical policy 154 is BCBSMA’s MAC policy, which basically allows MAC only in patients who have certain risk factors (e.g., PS III or higher, sleep apnea, under 18 or over 70, etc.).  MAC is deemed not medically necessary “in patients at average risk related to use of anesthesia and sedation.” 

Because of these restrictions, some providers may believe that using a general anesthetic would enhance the chances of getting paid, since the MAC policy would no longer apply.  However, the above excerpt could be interpreted to mean that BCBSMA deems only moderate sedation and MAC as payable under this policy, meaning a general might not be paid under any circumstance in endoscopic cases. 

So, you say: “I’ll just submit an ABN-type of notification to those patients who do not meet the medical necessity threshold as found in the MAC policy, informing them that (a) the payer will deny their anesthesia service and, (b) it will be up to the patient to pay out of pocket.”  The problem is that the payer’s advisory goes on to say the following:

Note: if the endoscopic procedure is performed under monitored anesthesia care and does not align with medical policy 154, the member is not liable to the non-covered amount.

This would seem to imply that the provider is prohibited from billing the patient for this non-covered service.  Again, the new BCBSMA policy is just the latest example that demonstrates the increasing difficulty in getting paid in GI cases across the payer spectrum.  So, what is one to do?

Documentation Is Critical

It will be more important than ever for the anesthesia provider to be familiar with the GI policies of your major payers—especially as they relate to anesthesia services.  For those payers that place restrictions on the medical necessity of anesthesia for these types of cases, you will want to ensure your documentation sufficiently supports payment for your service.  Part of this process is understanding the anesthesia codes for GI that are available to you.

There are currently five anesthesia codes that cover anesthesia for GI procedures.  They are as follows:

• 00731 (5) Upper GI, no mention of ERCP
• 00732 (6) Upper GI for ERCP
• 00811 (4) Lower GI, no mention of screening colonoscopy
• 00812 (4 or 3, depending on insurance) screening colonoscopy
• 00813 (5) Upper and lower GI

The number in parentheses adjacent to each anesthesia code reflects the base unit value of the code as determined by the American Society of Anesthesiologists (ASA) and published in their Relative Value Guide (RVG). 

Due to the variation in codes and their descriptors, your documentation should state whether the procedure involved upper, lower, or both upper and lower, GI.  You should indicate whether or not ERCP was involved.  For colonoscopies, you should state whether or not it was a screening.  If so, you should state whether or not any intervention was performed (e.g., biopsy, polypectomy).  Finally, you should list any patient co-morbidities or history that might bolster the medical necessity for your anesthesia service, paying particular attention to any payer policies in this regard.

We all know that new hurdles to reimbursement are being placed in your path each year.  This is especially true when it comes to GI cases.  As always, your vigilance as it pertains to payer policies and your detailed documentation of the medical record stand as your best response to a changing reimbursement landscape.

If you have questions about this topic, please contact your account executive.