Ketamine in an Anesthesia Clinic

Summary
With the growing popularity and usage of Ketamine as both an anesthetic and therapeutic agent, some anesthesia practices are considering adding Ketamine infusion therapy to their line of business. This article addresses the pros and cons of setting up a Ketamine clinic.

Ketamine is a powerful anesthetic agent well known to all anesthesia providers. It is widely used in today's operating rooms. However, there is now growing discussion and serious consideration of using Ketamine outside the operating room and moving it into clinics, with the intention of helping patients suffering from severe depression. The number of such clinics is relatively small at this time, but their existence raises the interesting question as to whether anesthesia practices should consider such an extension of this service line.

Digging into the Drug

Ketamine is a medication mainly used for starting and maintaining anesthesia. It induces a trance-like state while providing pain relief, sedation and memory loss. Having been discovered in 1962 and first approved in 1964, it proved to be a particularly effective anesthetic agent in the Vietnam war. Pharmacologically, it is related to LSD.

One of the reasons for Ketamine's growing popularity is that it has been hailed as a non-opioid solution for addressing patients' pain. With the opioid epidemic in full swing, this has been seen as a viable alternative in some clinical circumstances. However, there is now some debate over whether Ketamine is a true non-opioid. A recent Stanford University study concluded that the drug is, in fact, an opioid, or at least acts as such within the brain. Experts at Johns Hopkins School of Medicine are on record as being in opposition to the Stanford findings. So, for the present, we have two of the most eminent research institutions in the country taking a different stance on the very nature of this drug.

Weapon Against Depression

In addition to being an effective pain-reliever, Ketamine has also been found to be a rapid-acting antidepressant. It may also be effective in decreasing suicidal ideation, although this conclusion is based on lower quality evidence. The antidepressant effects of Ketamine were first shown in small studies in 2000 and 2006. They have since been demonstrated and characterized in subsequent studies. It is this aspect of the drug that is creating an alternate line of treatment and the reason some are opening up Ketamine therapy clinics.

It has been found that a single, low, sub-anesthetic dose of Ketamine given via intravenous infusion may produce antidepressant effects within four hours in people with depression. Such effects may persist for up to several weeks following a single infusion. This is in contrast to conventional antidepressants like selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants (TCAs), which generally require at least several weeks for their benefits to reach maximum effect. Moreover, based on the available preliminary evidence, the magnitude of the antidepressant effects of Ketamine appears to be more than double that of conventional antidepressants. On the basis of these findings, Ketamine has been described as the single most important advancement in the treatment of depression in over 50 years. It has sparked interest in NMDA receptor antagonists for depression, and has shifted the direction of antidepressant research and development.

The Treatment Process

A Ketamine clinic is based on infusion protocols. Patients may undergo multiple sessions of an hour or more. According to one Ketamine treatment center, their therapy consists of the following steps:

Stabilization Period

• The patient undergoes a series of initial treatments during a one- to two-week period.
• Each infusion session lasts one hour.
• Number of Treatments: 4-6 total, based on the screening process.

Maintenance Period

• This period refers to all ongoing treatments after stabilization.
• The maintenance schedule varies for each patient, but the typical schedule begins approximately ten days after the last stabilization treatment.
• The next treatment occurs approximately one month after the stabilization period treatments.
• The maintenance schedule varies based on the patient's needs with the goal of progressing into longer intervals between treatments.

Reimbursement Considerations

Getting paid for these sessions can be a challenge. In particular, very specific coding guidelines must be met, and the place of service (POS) is critical. In the office setting (POS 11), we code 96365 (intravenous infusion, for therapy, prophylaxis, or diagnosis; initial, up to 1 hour) and 96366 (each additional hour). Per CPT guidelines, Ketamine infusion (96365) is not intended to be reported by the physician or other qualified health care professional in the facility setting. The correct coding would be the appropriate Evaluation and Management (E/M) code with additional code(s) for prolonged services (99354-99355). The prolonged service time would start after the end of the visit level time. For example, if the visit was coded with CPT 99214, the time listed for that code is 25 minutes; so, the prolonged service time would start at 26 minutes. Face-to-face prolonged services involve time-based codes. The provider must document the total duration of time for the service. The time spent does not have to be continuous on the date of service. Prolonged services under 30 minutes of total duration is not separately reported.

Because Ketamine therapy is being used by some providers to treat depression, PTSD or similar issues, some payers, specialty societies or governing agencies may eventually question the propriety of anesthesiologists or pain practitioners delving into mental health therapies. Then, again, they may ultimately determine that such providers are uniquely qualified to render such treatment. Erring on the side of caution, we recommend that providers thinking about adding this type of treatment to their line of business thoroughly investigate whether or not Ketamine therapy is precluded for their specialty under the scope of practice statutes or rules within their state. We will be keeping an eye out for any authoritative ruling that may be forthcoming in this regard and will pass that along.