Anesthesia Unnecessary for ESIs effective 12/12/2021

Effective December 12th CMS will be implementing changes to its National Coverage Policy.
https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?LCDId=36920
 
Item 4 under Limitations has been brought to our attention:
Use of Moderate or Deep Sedation, General Anesthesia, or Monitored Anesthesia Care (MAC) is usually unnecessary or rarely indicated for these procedures and therefore, is not considered medically reasonable and necessary.16 Even in patients with a needle phobia and anxiety, typically oral anxiolytics suffice. In exceptional and unique cases, documentation must clearly establish the need for such sedation in the specific patient.
 
ASA Director of Payment and Practice Management Sharon Merrick has confirmed that ASA’s stance on this issue is included in the ASA’s Statement on Anesthetic Care During Interventional Pain Procedures for Adults which was created by the ASA Committee on Pain Medicine. The statement underwent minor revisions as part of its 5-year review, but the main elements are still in place.
 
The statement provides examples of when anesthesia care or sedation could be necessary. The version on the ASA website (which should soon be updated to reflect the edits made at the recent HOD) notes that “Significant anxiety may be an indication for moderate (conscious) sedation or anesthesia services. In addition, procedures that require the patient to remain motionless for a prolonged period of time and/or remain in a painful position may require sedation or anesthesia services. Examples of such procedures include but are not limited to sympathetic blocks (celiac plexus, paravertebral and hypogastric), chemical or radiofrequency ablation, percutaneous discectomy, trial spinal cord stimulator lead placement, permanent spinal cord stimulator generator and lead implantation, and intrathecal pump implantation.”
 
The ASA CROSSWALK® is consistent with this statement but does specifically point out that “Although anesthesia care is not typically required, coverage/payment should not be routinely denied when medically necessary.”  A claim for anesthesia care for ESI should include documentation to support that need. The ICD-10-CM coding should include not only the reason the patient needed the procedure, but also the reason the anesthesia was necessary.

HHS Announces New COVID Relief Funding and Extension of First PRF Reporting Deadline

The Department of Health and Human Services (HHS), through the Health Resources and Services Administration (HRSA), announced $25.5 billion in new funding for health care providers affected by the COVID-19 pandemic. This funding includes $8.5 billion in American Rescue Plan (ARP) resources for providers who serve rural Medicaid, Children’s Health Insurance Program (CHIP), or Medicare patients, and an additional $17 billion for Provider Relief Fund (PRF) Phase 4 for a broad range of providers who can document revenue loss and expenses associated with the pandemic.

The application will open on September 29, 2021. Providers will apply for both programs in a single application and HRSA will use existing Medicaid/CHIP and Medicare claims data in calculating portions of these payments.

Phase 4 General Distribution – $17 billion will be distributed based on providers’ lost revenues and changes in operating expenses from July 1, 2020 to March 31, 2021.

To promote equity and to support providers with the most need, HRSA will:

  • Reimburse a higher percentage of lost revenues and expenses for smaller providers as compared to larger providers.
  • Provide “bonus” payments based on the amount of services provided to Medicaid, CHIP, and Medicare patients, priced at the generally higher Medicare rates.
  • American Rescue Plan (ARP) Rural — $8.5 billion based on the amount of services providers furnish to Medicaid/CHIP and Medicare beneficiaries living in Federal Office of Rural Health Policy (FORHP)-defined rural areas.
  • Providers can review eligibility information posted on the PRF Future Payments web page Additional detail will be added prior to September 29.Providers can review eligibility information posted on the PRF Future Payments web page Additional detail will be added prior to September 29.
  • HHS also released detailed information about the methodology utilized to calculate Phase 3 payments. Providers who believe their Phase 3 payment was not calculated correctly according to this methodology will now have an opportunity to request a reconsideration.

Grace Period for Reporting Period 1

In light of the challenges providers across the country are facing due to recent natural disasters and the Delta variant, HHS is also announcing a final 60-day grace period to help providers come into compliance with the September 30, 2021 deadline for the first PRF Reporting Time Period. While the deadlines to use funds and the Reporting Time Period will not change, HHS will not initiate collection activities or similar enforcement actions for noncompliant providers during this grace period. Several helpful resources can be found at on the PRF Reporting web page.