Medicare FFS Claims: 2% Payment Adjustment (Sequestration) Suspended Through December

Anesthesia Unnecessary for ESIs effective 12/12/2021

Effective December 12^th 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.