RETIRED Moderate Sedation Policy

Transcription

1 Policy Number 2016R0035A Annual Approval Date RETIRED Moderate Sedation Policy 7/13/2016 Approved By REIMBURSEMENT POLICY Payment Policy Oversight Committee IMPORTANT NOTE ABOUT THIS REIMBURSEMENT POLICY You are responsible for submission of accurate claims. This reimbursement policy is intended to ensure that you are reimbursed based on the code or codes that correctly describe the health care services provided. UnitedHealthcare Community Plan reimbursement policies uses Current Procedural Terminology (CPT *), Centers for Medicare and Medicaid Services (CMS) or other coding guidelines. References to CPT or other sources are for definitional purposes only and do not imply any right to reimbursement. This reimbursement policy applies to all health care services billed on CMS 1500 forms and, when specified, to those billed on UB04 forms. Coding methodology, industry-standard reimbursement logic, regulatory requirements, benefits design and other factors are considered in developing reimbursement policy. This information is intended to serve only as a general reference resource regarding UnitedHealthcare Community Plan s reimbursement policy for the services described and is not intended to address every aspect of a reimbursement situation. Accordingly, UnitedHealthcare Community Plan may use reasonable discretion in interpreting and applying this policy to health care services provided in a particular case. Further, the policy does not address all issues related to reimbursement for health care services provided to UnitedHealthcare Community Plan enrollees. Other factors affecting reimbursement supplement, modify or, in some cases, supersede this policy. These factors include, but are not limited to: federal &/or state regulatory requirements, the physician or other provider contracts, the enrollee s benefit coverage documents, and/or other reimbursement, medical or drug policies. Finally, this policy may not be implemented exactly the same way on the different electronic claims processing systems used by UnitedHealthcare Community Plan due to programming or other constraints; however, UnitedHealthcare Community Plan strives to minimize these variations. UnitedHealthcare Community Plan may modify this reimbursement policy at any time by publishing a new version of the policy on this Website. However, the information presented in this policy is accurate and current as of the date of publication. UnitedHealthcare Community Plan uses a customized version of the Optum Claims Editing System known as ices Clearinghouse to process claims in accordance with UnitedHealthcare Community Plan reimbursement policies.*cpt is a registered trademark of the American Medical Association Proprietary information of UnitedHealthcare Community and State Copyright 2016 United HealthCare Services, Inc. Application This reimbursement policy applies to UnitedHealthcare Community Plan Medicaid and Medicare products. This reimbursement policy applies to services reported using the 1500 Health Insurance Claim Form (a/k/a ) or its electronic equivalent or its successor form. This policy applies to all products and all network and non-network physicians and other qualified health care professionals, including, but not limited to, non-network authorized and percent of charge contract physicians and other qualified health care professionals. This policy applies to claims with dates of service prior to 1/1/2017. For claims with dates of service on or after 1/1/2017 refer to the CCI Editing Policy and the Rebundling Policy. Payment Policies for Medicare & Retirement and Employer & Individual please use this link. Medicare & Retirement Policies are listed under Medicare Advantage Reimbursement Policies.

2 Employer & Individual are listed under Reimbursement Policies-Commercial. Policy Overview Current Procedural Terminology (CPT ) defines Moderate (conscious) Sedation as a drug induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. In addition, no interventions are required to maintain a patent airway and spontaneous ventilation is adequate. Cardiovascular function is usually maintained. Moderate Sedation does not include Minimal Sedation (anxiolysis), deep sedation or monitored anesthesia care ( ). Moderate Sedation services reported by the Same Physician or Other Qualified Health Care Professional reporting the diagnostic or therapeutic procedure, are separately reimbursable services when submitted under CPT codes except when reported with the procedures noted below. In a facility setting, Moderate Sedation services performed by a second physician or other qualified health care professional are separately reimbursable services when submitted under CPT codes In a non-facility setting, CPT codes will not be reimbursed when the same or different physician or other qualified health care professional also reports a code listed in Appendix G of the CPT codebook. Note: Based on their intended use, Moderate Sedation codes would not be reported with diagnostic or therapeutic procedures. UnitedHealthcare Community Plan s reimbursement policy for Moderate Sedation services is based on methodologies used and recognized by the Centers for Medicare and Medicaid Services (CMS) National Correct Coding Initiative (NCCI) edits and Policy Manual, and CPT codebook guidelines. For purposes of this policy, Same Physician or Other Qualified Health Care Professional is defined as the same individual rendering health care services reporting the same Federal Tax Identification number. Reimbursement Guidelines Attending Physician ( ) UnitedHealthcare Community Plan will allow separate reimbursement for Moderate Sedation services reported using CPT codes when provided by the Same Physician or Other Qualified Health Care Professional reporting the diagnostic or therapeutic procedure except when reported with: 1) Procedures listed in Appendix G of the CPT book 2) Anesthesia procedures (CPT codes ) 3) CPT and HCPCS codes that are part of CMS NCCI edits These procedures include Moderate Sedation as an inherent part of providing the service. Refer to the list below for a comprehensive listing of the non-anesthesia procedures that include Moderate Sedation and for which CPT codes will not be considered separately. UnitedHealthcare Community Plan Procedures that include Moderate Sedation Codes ( ) Note: Procedure codes that are listed in Appendix G of the CPT book that are also identified on the National Physician Fee Schedule (NPFS) as Status B are addressed in the B Bundle Codes Policy. Second Physician ( )

3 Moderate Sedation services performed by a second physician or other qualified health care professional (who is not performing the diagnostic or therapeutic procedure that the sedation supports), should be reported as CPT codes Reimbursement of CPT codes based on the place of service is as follows: Non-facility setting According to the AMA When moderate sedation is performed in the non-facility setting, the efforts of the second physician are not reported with the codes in Appendix G because moderate sedation is included in these codes. Therefore, it would not be appropriate to separately report for moderate sedation. Based on AMA guidelines, UnitedHealthcare Community Plan will reimburse CPT codes in a nonfacility setting except when a procedure code listed in Appendix G of the CPT codebook is also reported on the same date of service by the same or different physician or other qualified health care professional. Facility setting Moderate Sedation services reported as CPT codes that are performed by a second physician or other qualified health care professional in a facility place of service (see listing below) are eligible for reimbursement. For purposes of this policy a facility place of service would include any of the following locations: 19 Off Campus-Outpatient Hospital 21 Inpatient Hospital 22 On Campus-Outpatient Hospital 23 Emergency Room-Hospital 24 Ambulatory Surgical Center 26 Military Treatment Facility 31 Skilled Nursing Facility 34 Hospice 41 Ambulance - Land 42 Ambulance - Air or Water 51 Inpatient Psychiatric Facility 52 Psychiatric Facility - Partial Hospitalization 53 Community Mental Health Center 56 Psychiatric Residential Treatment Center 61 Comprehensive Inpatient Rehabilitation Facility For additional information, refer to the Questions and Answers section, Q&A #1 and #3. Drug Reimbursement The cost of the drug used in Moderate Sedation, if supplied by the physician in a location other than inpatient/outpatient hospital, emergency room or ambulatory surgical center, is reimbursable at the appropriate fee schedule or contracted rate. For additional information on drugs supplied in an inpatient/outpatient hospital, emergency room or ambulatory surgical center, refer to the Supply Policy. State Exceptions Wisconsin CPT codes are not reimbursable due to Wisconsin Regulations. Wisconsin has a state specific list of codes that are included in the Non Covered Codes policy.

4 Definitions Minimal Sedation Moderate Sedation Same Physician or Other Qualified Health Care Professional REIMBURSEMENT POLICY Minimal Sedation (anxiolysis) is a drug-induced state during which patients respond normally to verbal commands. Although cognitive function and coordination may be impaired, ventilatory and cardiovascular functions are unaffected. Moderate (conscious) Sedation is a drug induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained. Moderate Sedation does not include Minimal Sedation (anxiolysis), deep sedation, or monitored anesthesia care (CPT codes ). The same individual rendering health care services reporting the same Federal Tax Identification number. Questions and Answers Q: A second physician has rendered Moderate Sedation in a non-facility setting for a procedure listed in Appendix G of the CPT codebook reported by the attending physician. Will the second physician s services be separately reimbursed? A: No. When Moderate Sedation is performed in the non-facility setting, the efforts of the second physician are not reported with the codes in Appendix G because Moderate Sedation is included in these codes. In a non-facility setting the second physician is considered the "trained observer," and should be reimbursed by the attending physician. Q: In the policy overview it states: Moderate Sedation does not include Minimal Sedation (anxiolysis). What are some examples of Minimal Sedation? A: According to the report titled Practice Guidelines for Sedation and Analgesia by Non- Anesthesiologists (obtained from the ASA website), "Examples of minimal sedation include peripheral nerve blocks, local or topical anesthesia, and either (1) less than 50% nitrous oxide (N2O) in oxygen with no other sedative or analgesic medications by any route, or (2) a single, oral sedative or analgesic medication administered in doses appropriate for the unsupervised treatment of insomnia, anxiety, or pain." Q: Why would it be appropriate to report CPT codes for an Appendix G procedure when performed in a facility place of service? A: According to the AMA, the provision of sedation by a second provider would not be the normal course of action and that implies a different intensity of work for these services than would be the case when it is inherent to the procedure. This work would properly be performed in a facility, not a non-facility, place of service Codes CPT code section Moderate sedation services (other than those services described by codes ) provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patients level of consciousness and

5 physiological status; younger than 5 years of age, first 30 minutes intraservice time Moderate sedation services (other than those services described by codes ) provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patients level of consciousness and physiological status; age 5 years or older, first 30 minutes intra-service time Moderate sedation services (other than those services described by codes ) provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patients level of consciousness and physiological status; each additional 15 minutes intra-service time (List separately in addition to code for primary service) Moderate sedation services (other than those services described by codes ), provided by a physician or other qualified health care professional other than the health care professional performing the diagnostic or therapeutic service that the sedation supports; younger than 5 years of age, first 30 minutes intra-service time Moderate sedation services (other than those services described by codes ), provided by a physician or other qualified health care professional other than the health care professional performing the diagnostic or therapeutic service that the sedation supports; age 5 years or older, first 30 minutes intra-service time Moderate sedation services (other than those services described by codes ), provided by a physician or other qualified health care professional other than the health care professional performing the diagnostic or therapeutic service that the sedation supports; each additional 15 minutes intra-service time (List separately in addition to code for primary service) Attachments: Please right-click on the icon to open the file. UnitedHealthcare Community Plan Procedures that include Moderate Sedation Codes ( ) This comprehensive list identifies the codes contained in Appendix G of the CPT book and codes that are part of CMS NCCI edits for procedures that include Moderate Sedation services. The codes on this list do not allow separate reimbursement for Moderate Sedation codes Resources Individual state Medicaid regulations, manuals & fee schedules American Medical Association, Current Procedural Terminology ( CPT ) and associated publications and services

6 Centers for Medicare and Medicaid Services, CMS Manual System and other CMS publications and services Centers for Medicare and Medicaid Services, National Correct Coding Initiative (NCCI) publications Publications and services of the American Society of Anesthesiologists (ASA) History 1/1/2017 Policy Retired 7/13/2016 Policy Approval Date Change (no new version) 1/1/2016 Annual Policy Version Change Policy Verbiage Change: Updated the Reimbursement Guidelines section to add place of service 19 Policy List Change: Updated Procedures that include Moderate Sedation Codes ( ) History Section: Entries prior to 1/1/2014 archived 3/1/2015 Application Section: Removed reference to location of policy for Mississippi Chip (no new version) 1/1/2015 Annual Version Change History Section: Entries prior to 1/1/13 archived 11/15/2014 Policy Verbiage Change: Updated Overview and Reimbursement Guidelines section for CPT codes (Second Physician) Questions and Answers Section: Updated Q&A #1; added Q&A #3 State Exceptions Section Updated: Verbiage change for Wisconsin 9/8/2014 Resources Section: Updated (no new version) Application Section: Updated 8/4/2014 Application Section: Removed reference to location of policy for Florida Medicaid and Rhode Island Medicaid, added including, but not limited to verbiage, and added verbiage stating this policy applies to UnitedHealthcare Community Plan Medicaid and Medicare products. 3/31/2014 Disclaimer: Revised 2/16/2014 Policy List Change: UnitedHealthcare Community Plan Procedures that include Moderate Sedation Codes ( ) 1/27/2014 Annual renewal of policy approved by United HealthCare Community & State Payment Policy Committee 1/7/2014 Policy List Change: UnitedHealthcare Community Plan Procedures that include Moderate Sedation Codes ( ) 1/1/2014 Annual Version Change Policy List Change: Policy List Name Change: Codes that include CPT codes replaced with Procedures that include Moderate Sedation Codes ( ) Policy Verbiage Change: Added diagnostic or therapeutic procedure, removed medical or surgical procedure; all defined terms capitalized Definitions: all defined terms capitalized Back To Top