FRONT Front
Contractor Name
HealthNow
Contractor Number
00801
Contractor Type
Carrier
LCD Database ID Number
L3645
LCD Title
Anesthesia for Gastrointestinal Endoscopy
Contractor's Determination Number
AN001E05 End dated
AMA CPT / ADA CDT Copyright Statement
CPT codes, descriptions and other data only are copyright 2006 American
Medical Association (or such other date of publication of CPT). All
Rights Reserved. Applicable FARS/DFARS clauses apply. Current Dental
Terminology (CDT) (including procedure codes, nomenclature, descriptors
and other data contained therein) is copyright by the American Dental
Association. (C) 2002 2004 American Dental Association. All rights
reserved. Applicable FARS/DFARS apply.
CMS National Coverage Policy
- Title XVIII of the Social Security Act, section 1862(a)(7)
This section excludes routine physical checkups.
- Title XVIII of the Social Security Act, section 1862(a)(1)(A)
This section allows coverage and payment for only those services that
are considered to be reasonable and necessary.
- Title XVIII of the Social Security Act, section 1833 (e)
This section prohibits Medicare payment for any claim that lacks the
necessary information for processing.
- CMS Manual System, Pub 100-4, Medicare Claims Processing, Chapter 12,
Sections 50, 50K and 140.3.2
These sections state no separate payment should be made for the
anesthesia service performed by the physician who also furnishes the
medical or surgical service.
Primary Geographic Jurisdiction
Upstate New York
Oversight Region
Region II
CMS Consortium
Northeast
Original Determination Effective Date
11/01/1998
Original Determination Ending Date
05/15/2008
Revision Effective Date
05/15/2007
Revision Ending Date
05/15/2008
Indications and Limitations of Coverage and/or Medical Necessity
Patients undergoing gastrointestinal endoscopy receive medications for
anxiety, discomfort and anesthesia, as well as monitoring during the
procedure.
Indications
1. Patients undergoing upper and lower gastrointestinal endoscopy
frequently receive medication for sedation, relief of anxiety and
discomfort. "General anesthesia or the presence of an anesthesiologist
is rarely indicated except in special circumstances...the endoscopy
team should be trained in cardiopulmonary resuscitation." (Preparation
of Patients for Gastrointestinal Endoscopy, Guidelines for Clinical
Application, American Society Gastrointestinal Endoscopy, publication
#1016).
2. Administration of medication and monitoring of the patient are
performed by the endoscopy team, and the presence of an
anesthesiologist/anesthetist will be deemed to be medically
unnecessary except in those rare instances when a patient has a
pre-existing unstable medical condition. Patients on a respirator are
not considered unstable just because of their dependence on a
respirator; in fact, these patients may be less in need of an
anesthesiologist/anesthetist since their airway is protected and their
respirations controlled.
3. It would seem inappropriate for any patient so medically unstable as
to require the presence of an anesthesiologist/anesthetist to undergo
an endoscopic procedure in the office setting.
4. Services by an anesthesiologist/anesthetist for administration of
anesthesia for gastrointestinal endoscopy in the in-patient,
out-patient, or ambulatory facility setting, where the only indication
for the presence of an anesthesiologist or anesthetist is compliance
with hospital or ASC policy, will be deemed to be medically
unnecessary and not eligible for Medicare Part B reimbursement.
5. Anesthesia services provided as "standby" are covered as part of the
facility charge and are reimbursable under the Part A facility charge
to hospitals and under the Part B facility charge to ASCs. These
services may not be billed to the beneficiary.
6. Administration of anesthesia by the performing surgeon (endoscopist)
is included in the reimbursement for the surgical procedure
(endoscopy).
7. Young children and pediatric patients may require the presence of an
anesthesiologist/anesthetist for anesthesiology during endoscopy.
8. Patients with severe, uncontrolled hypertension (diastolic BP of 110
or greater) at the time of the endoscopy, may require the presence of
an anesthesiologist/anesthetist. It would, however, seem inappropriate
for any such patient with uncontrolled hypertension to undergo any
endoscopic procedure except for gastrointestinal emergencies.
Therefore, unless the blood pressure is in the range indicated,
anesthesia by an anesthesiologist/anesthetist is not considered to be
medically necessary.
9. Patients with acute asthma, acute thyrotoxicosis, acute, inadequately
treated adrenal insufficiency, or diabetic ketoacidosis or coma may
require the presence of an anesthesiologist/anesthetist if these
conditions are active medical problems requiring treatment at the time
of the endoscopy.
10. The presence of an anesthesiologist/anesthetist may be required for
patients with psychiatric diagnoses if their condition prevents them
from cooperating with the endoscopist during the procedure (such as
acute drug or alcohol intoxication, or acute confusional state) and
for patients requiring unusual sedation or anesthesia.
11. The conditions supporting medical necessity are presumed to be active
medical problems at the time of the endoscopic procedure.
12. The presence of an anesthesiologist/anesthetist may be required for
patients undergoing an unusually difficult endoscopic procedure or one
accompanied by unusual amounts of pain or discomfort. These services
should be coded with ICD-9-CM diagnosis codes 530.9, 537.9 or 569.9,
BUT must be accompanied by a report explaining the unusual
circumstances. These claims will be reviewed to determine whether the
anesthesia service is reimbursable. It is expected that such coding
will be an infrequent event and not routine.
13. The presence of an anesthesiologist/anesthetist may be required for
patients with anal/rectal stenosis (ICD-9-CM 569.2) and patients
undergoing dilatation of the esophagus for cancer or
stricture/stenosis (ICD-9-CM diagnoses codes 150.9 and 530.3).
14. The presence of an anesthesiologist/anesthetist may be required for
patients undergoing endoscopic procedures when intravenous propofol or
a paralytic agent is administered (use ICD-9-CM code V58.83).
Coverage Topic
Anesthesia (Inpatient)
Anesthesia (Outpatient)
CPT/HCPCS Codes
00740 Anesthesia for upper gastrointestinal endoscopic procedures, endoscope introduced proximal to duodenum
00810 Anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum
Does the CPT 30% Coding Rule Apply?
No
ICD-9 Codes that Support Medical Necessity
TRUNCATED DIAGNOSIS CODES ARE NOT ACCEPTABLE.
ICD-9-CM code listings may cover a range and include truncated codes. It is the provider's responsibility to avoid truncated codes by selecting a code(s) carried out to the highest level of specificity and selected from the ICD-9-CM code book appropriate to the year in which the service was performed.
It is not enough to link the procedure code to a correct, payable ICD-9-CM diagnosis code. The diagnosis or clinical signs/symptoms must be present for the procedure to be paid. Further, these ICD-9-CM codes can be used only with the conditions listed in the "Indications and Limitations of coverage and/or Medical Necessity" section of this policy.
ICD-9-CM code V58.83 should be used only for anesthesia utilizing intravenous propofol or a paralytic agent.
* This ICD-9 CM code is new effective for dates of service on or after 10/01/2005.
290.11 Presenile dementia with delirium
290.12 Presenile dementia with delusional features
290.13 Presenile dementia with depressive features
290.20 Senile dementia with delusional features
290.21 Senile dementia with depressive features
290.3 Senile dementia with delirium
290.40 Vascular dementia, uncomplicated
290.41 Vascular dementia, with delirium
290.42 Vascular dementia, with delusions
290.43 Vascular dementia, with depressed mood
290.8 Other specified senile psychotic conditions
290.9 Unspecified senile psychotic condition
291.0 Alcohol withdrawal delirium
291.1 Alcohol-induced persisting amnestic disorder
291.2 Alcohol-induced persisting dementia
291.3 Alcohol-induced psychotic disorder with hallucinations
291.4 Idiosyncratic alcohol intoxication
291.5 Alcohol-induced psychotic disorder with delusions
291.81 Alcohol withdrawal
291.9 Unspecified alcohol-induced mental disorders
292.0 Drug withdrawal
292.11 Drug-induced psychotic disorder with delusions
292.12 Drug-induced psychotic disorder with hallucinations
292.2 Pathological drug intoxication
292.81 Drug-induced delirium
292.82 Drug-induced persisting dementia
292.83 Drug-induced persisting amnestic disorder
292.84 Drug-induced mood disorder
292.85* Drug induced sleep disorders
292.9 Unspecified drug-induced mental disorder
293.0 Delirium due to conditions classified elsewhere
293.1 Subacute delirium
293.81 Psychotic disorder with delusions in conditions classified elsewhere
293.82 Psychotic disorder with hallucinations in conditions classified elsewhere
293.83 Mood disorder in conditions classified elsewhere
293.84 Anxiety disorder in conditions classified elsewhere
293.89 Other specified transient mental disorders due to conditions classified elsewhere, other
293.9 Unspecified transient mental disorder in conditions classified elsewhere
294.0 Amnestic disorder in conditions classified elsewhere
294.10 Dementia in conditions classified elsewhere without behavioral disturbance
294.11 Dementia in conditions classified elsewhere with behavioral disturbance
294.8 Other persistent mental disorders due to conditions classified elsewhere
294.9 Unspecified persistent mental disorders due to conditions classified elsewhere
303.00 Acute alcoholic intoxication, unspecified
303.01 Acute alcoholic intoxication, continuous
303.02 Acute alcoholic intoxication, episodic
303.90 Other and unspecified alcohol dependence, unspecified
303.91 Other and unspecified alcohol dependence, continuous
303.92 Other and unspecified alcohol dependence, episodic
304.00 Opioid type dependence, unspecified
304.01 Opioid type dependence, continuous
304.02 Opioid type dependence, episodic
304.10 Sedative, hypnotic or anxiolytic dependence, unspecified
304.11 Sedative, hypnotic or anxiolytic dependence, continuous
304.12 Sedative, hypnotic or anxiolytic dependence, episodic
304.20 Cocaine dependence, unspecified
304.21 Cocaine dependence, continuous
304.22 Cocaine dependence, episodic
304.30 Cannabis dependence, unspecified
304.31 Cannabis dependence, continuous
304.32 Cannabis dependence, episodic
304.40 Amphetamine and other psychostimulant dependence, unspecified
304.41 Amphetamine and other psychostimulant dependence, continuous
304.42 Amphetamine and other psychostimulant dependence, episodic
304.50 Hallucinogen dependence, unspecified
304.51 Hallucinogen dependence, continuous
304.52 Hallucinogen dependence, episodic
304.60 Other specified drug dependence, unspecified
304.61 Other specified drug dependence, continuous
304.62 Other specified drug dependence, episodic
304.70 Combinations of opioid type drug with any other, unspecified
304.71 Combinations of opioid type drug with any other, continuous
304.72 Combinations of opioid type drug with any other, episodic
304.80 Combinations of drug dependence excluding opioid type drug, unspecified
304.81 Combinations of drug dependence excluding opioid type drug, continuous
304.82 Combinations of drug dependence excluding opioid type drug, episodic
304.90 Unspecified drug dependence, unspecified
304.91 Unspecified drug dependence, continuous
304.92 Unspecified drug dependence, episodic
305.00 Alcohol abuse, unspecified
305.01 Alcohol abuse, continuous
305.02 Alcohol abuse, episodic
305.20 Cannabis abuse, unspecified
305.21 Cannabis abuse, continuous
305.22 Cannabis abuse, episodic
305.70 Amphetamine or related acting sympathomimetic abuse, unspecified
305.71 Amphetamine or related acting sympathomimetic abuse, continuous
305.72 Amphetamine or related acting sympathomimetic abuse,
317 Mild mental retardation (high grade defect, IQ 50-70)
318.0 Moderate mental retardation (IQ 35-49)
318.1 Severe mental retardation (IQ 20-34)
318.2 Profound mental retardation (IQ under 20)
319 Unspecified mental retardation
331.0 Alzheimer's disease
410.00 Acute myocardial infarction of anterolateral wall, episode of care unspecified
410.01 Acute myocardial infarction of anterolateral wall, initial episode of care
410.02 Acute myocardial infarction of anterolateral wall, subsequent episode of care
410.10 Acute myocardial infarction of other anterior wall, episode of care unspecified
410.11 Acute myocardial infarction of other anterior wall, initial episode of care
410.12 Acute myocardial infarction of other anterior wall, subsequent episode of care
410.20 Acute myocardial infarction of inferolateral wall, episode of care unspecified
410.21 Acute myocardial infarction of inferolateral wall, initial episode of care
410.22 Acute myocardial infarction of inferolateral wall, subsequent episode of care
410.30 Acute myocardial infarction of inferoposterior wall, episode of care unspecified
410.31 Acute myocardial infarction of inferoposterior wall, initial episode of care
410.32 Acute myocardial infarction of inferoposterior wall, subsequent episode of care
410.40 Acute myocardial infarction of other inferior wall, episode of care unspecified
410.41 Acute myocardial infarction of other inferior wall, initial episode of care
410.42 Acute myocardial infarction of other inferior wall, subsequent episode of care
410.50 Acute myocardial infarction of other lateral wall, episode of care unspecified
410.51 Acute myocardial infarction of other lateral wall, initial episode of care
410.52 Acute myocardial infarction of other lateral wall, subsequent episode of care
410.60 Acute myocardial infarction, true posterior wall infarction, episode of care unspecified
410.61 Acute myocardial infarction, true posterior wall infarction, initial episode of care
410.62 Acute myocardial infarction, true posterior wall infarction, subsequent episode of care
410.70 Acute myocardial infarction, subendocardial infarction, episode of care unspecified
410.71 Acute myocardial infarction, subendocardial infarction, initial episode of care
410.72 Acute myocardial infarction, subendocardial infarction, subsequent episode of care
410.80 Acute myocardial infarction of other specified sites, episode of care unspecified
410.81 Acute myocardial infarction of other specified sites, initial episode of care
410.82 Acute myocardial infarction of other specified sites, subsequent episode of care
410.90 Acute myocardial infarction, unspecified site, episode of care unspecified
410.91 Acute myocardial infarction, unspecified site, initial episode of care
410.92 Acute myocardial infarction, unspecified site, subsequent episode of care
411.1 Unstable angina
427.1 Paroxysmal ventricular tachycardia
427.41 Ventricular fibrillation
427.42 Ventricular flutter
428.1 Uncompensated congestive heart failure
428.20 Systolic heart failure, unspecified
428.21 Systolic heart failure, acute
428.23 Systolic heart failure, acute on chronic
428.30 Diastolic heart failure, unspecified
428.31 Diastolic heart failure, acute
428.33 Diastolic heart failure, acute on chronic
428.40 Combined systolic and diastolic heart failure, unspecified
428.41 Combined systolic and diastolic heart failure, acute
428.43 Combined systolic and diastolic heart failure, acute on chronic
456.0 Esophageal varices with bleeding
456.20 Esophageal varices with bleeding in diseases classified elsewhere
518.4 Acute edema of lung, unspecified
518.5 Pulmonary insufficiency following trauma and surgery
518.81 Respiratory failure
518.82 Other pulmonary insufficiency, not elsewhere classified
530.7 Gastroesophageal laceration-hemorrhage syndrome
530.82 Esophageal hemorrhage
531.00 Gastric ulcer, acute with hemorrhage, without mention of obstruction
531.01 Gastric ulcer, acute with hemorrhage, with obstruction
531.20 Acute gastric ulcer with hemorrhage and perforation, without mention of obstruction
531.21 Acute gastric ulcer with hemorrhage and perforation, with obstruction
531.40 Chronic or unspecified gastric ulcer with hemorrhage, without mention of obstruction
531.41 Chronic or unspecified gastric ulcer with hemorrhage, with obstruction
532.00 Acute duodenal ulcer with hemorrhage, without mention of obstruction
532.01 Acute duodenal ulcer with hemorrhage, with obstruction
532.20 Acute duodenal ulcer with hemorrhage and perforation without mention of obstruction
532.21 Acute duodenal ulcer with hemorrhage and perforation with obstruction
532.40 Chronic or unspecified duodenal ulcer with hemorrhage without mention of obstruction
532.41 Chronic or unspecified duodenal ulcer with hemorrhage and with obstruction
532.60 Chronic or unspecified duodenal ulcer with hemorrhage and perforation, without mention of obstruction
532.61 Chronic or unspecified duodenal ulcer with hemorrhage and perforation, with obstruction
533.00 Acute peptic ulcer with hemorrhage, without mention of obstruction, site unspecified
533.01 Acute peptic ulcer with hemorrhage, with obstruction, site unspecified
533.20 Acute peptic ulcer with hemorrhage and perforation, without mention of obstruction, site unspecified
533.21 Acute peptic ulcer with hemorrhage and perforation, with obstruction, site unspecified
533.40 Chronic or unspecified peptic ulcer with hemorrhage ,without mention of obstruction, site unspecified
533.41 Chronic or unspecified peptic ulcer with hemorrhage ,with obstruction, site unspecified
533.60 Chronic or unspecified peptic ulcer with hemorrhage and perforation, without mention of obstruction, site unspecified
533.61 Chronic or unspecified peptic ulcer with hemorrhage and perforation, with obstruction, site unspecified
534.00 Acute gastrojejunal ulcer with hemorrhage, without mention of obstruction
534.01 Acute gastrojejunal ulcer with hemorrhage, with obstruction
534.20 Acute gastrojejunal ulcer with hemorrhage and perforation, without mention of obstruction
534.21 Acute gastrojejunal ulcer with hemorrhage and perforation, with obstruction
534.40 Chronic or unspecified gastrojejunal ulcer with hemorrhage, without mention of obstruction
534.41 Chronic or unspecified gastrojejunal ulcer with hemorrhage, without mention of obstruction
534.60 Chronic or unspecified gastrojejunal ulcer with hemorrhage and perforation, without mention of obstruction
534.61 Chronic or unspecified gastrojejunal ulcer with hemorrhage and perforation, with obstruction
535.01 Acute gastritis with hemorrhage
535.11 Atrophic gastritis with hemorrhage
535.31 Alcoholic gastritis with hemorrhage
535.51 Unspecified gastritis and gastroduodenitis with hemorrhage
535.61 Duodenitis with hemorrhage
537.83 Angiodysplasia of stomach and duodenum with hemorrhage
537.84 Dieulafoy lesion (hemorrhagic) of stomach and duodenum)
569.2 Stenosis of rectum and anus
785.50 Shock without mention of trauma, unspecified
785.51 Cardiogenic shock
785.52 Septic shock
785.59 Other shock
786.09 Other respiratory abnormality
799.1 Respiratory arrest
935.0 Foreign body in mouth
935.1 Foreign body in esophagus
935.2 Foreign body in stomach
V58.83 Encounter for therapeutic drug monitoring
For patients undergoing dilatation of the esophagus procedures:
150.9 Malignant neoplasm of esophagus, unspecified
530.3 Stricture and stenosis of esophagus
For patients undergoing unusually difficult or painful endoscopies:
530.9 Unspecified disorder of the esophagus
537.9 Unspecified disorder of stomach and duodenum
569.9 Unspecified disorder of intestine
ICD-9 Codes that DO NOT Support Medical Necessity
Use of any ICD-9-CM code not listed in the "ICD-9-CM Codes That Support
Medical Necessity" section of this policy will be denied.
Documentation Requirements
1. Each claim must be submitted with ICD-9-CM codes that reflect the
condition of the patient, and indicate the reason(s) for which the
service was performed. Claims submitted without ICD-9-CM codes will be
returned.
2. The patient's record should document an appropriate history and
physical examination by the anesthesiologist/anesthetist specifying
the medical indications requiring his/her presence. The indications
should be recorded by both the anesthesiologist/anesthetist and the
endoscopist in their respective notes.
3. Claims billed by an anesthesiologist/anesthetist for anesthesia
provided to a patient undergoing an unusually difficult endoscopic
procedure or one accompanied by unusual amounts of pain or discomfort
will be reviewed. It is recommended that documentation explaining the
unusual circumstances necessitating the service be submitted with the
claim. Supporting documentation should identify patient-specific
reasons (data) such as: reports from prior endoscopies indicating
difficulty in completing the procedure; or unusual discomfort during
the anticipated difficulty; or prior upper gastrointestinal surgery
resulting in unusual anatomic relationship; or anticipated difficult
therapeutic endoscopies (ex., villous adenoma). These claims will be
reviewed to determine whether the anesthesia service is reimbursable.
4. Documentation must be available to Medicare upon request.Sources of Information and Basis for Decision
1. American Society of Gastrointestinal Endoscopy, publication #1016
2. Copyright (C) 2002, Physicians' Current Procedural Terminology,
American Medical Association
Advisory Committee Meeting Notes
This policy was presented at the June 11, 1997, Carrier Advisory Committee Meeting by Empire Medicare Services.
This policy does not reflect the sole opinion of the contractor or contractor medical director. Although the final decision rests with the contractor, this policy was developed in cooperation with advisory groups, which includes representatives from the American College of Gastroenterology, the American Society for Gastrointestinal Endoscopy, and the New York State Society of Anesthesiologists.
Start Date of Comment Period
06/11/1997
End Date of Comment Period
07/26/1997
Start Date of Notice Period
06/01/2007
Revision History Number
7
Revision History Explanation
This LCD is end dated because it is no longer an effective education tool.
Revision #7: Added ICD-9CM codes 331.0, 935.0, 935.1 and 935.2 as payable in response to a reconsideration request.
Revision #6: AN001E04 -- ICD-9-CM code 292.85 has been added, and ICD-9-CM codes 291.89 and 292.89 have been removed as a result of the 10/01/2005 ICD-9-CM update. ICD-9-CM code 291.82 removed as a correction. It was included in the range in error. Reformatted ICD-9-CM section. 45-Day notice period ends 07/23/2006.
Revision #5: As a result of the 10/01/2003 ICD-9-CM code update, ICD-9-CM code 785.52 was added as covered. As a result of CMS Change Request 2730, place of service (49) was added to "Coding Guideline" #12 as payable for claims received on or after 10/01/2003. Some format changes were made.
Revision # 4 - AN001E02:
This policy was revised with some minor formatting changes. The ICD-9-CM
section has been expanded to include the following ICD-9-CM codes for
dates of service on, or after, October 1, 2002: 428.20, 428.21, 428.23,
428.30, 428.31, 428.33, 428.40, 428.41, 428.43, and 537.84. "Documentation
Requirements" #3 has also been revised.
Revision #3 - AN001E01:
This policy was revised with some minor formatting changes, the modifier
section was corrected and appropriate places of service were added to the
"Coding Guidelines" section.
Revision # 2 - AN001E00:
Effective 12/27/2001. This policy is being revised at the request of the
New York State Society of Anesthesiologists to provide for the
reimbursement of patients undergoing endoscpic procedure utilizing
propofol or a paralytic agent (ICD-9-CM V58.83), for esophageal dilatation
(ICD-9-CM 150.9 and 530.3), anal/rectal stenosis (ICD-9-CM 569.2) or for
endoscopies accompanied by unusual difficulties or discomfort (ICD-9-CM
530.9, 537.9 and 569.9). Also added diagnosis code 319. It is now being
published under the New York's statewide policy number AN001E00 as a
second revision to A-97-3.
Revision #1 - A-97-3 (2A):
Effective 07/25/1999. This policy was originally published under Empire's
policy #Yanes03, UMD's policy # A-97-3 (2A) and GHI's policy # GI 1231 on
September 29, 1997. UMD's policy was revised 7/25/1999 to add ICD-9-CM
mental retardation diagnosis codes as recommended by the New York State
Society of Anesthesiologists. The revision was republished at that time
under the original policy numbers listed above.
This LCD was converted from an LMRP on 3/24/2004
Related Documents Article(s)
A19001 - Anesthesia for Gastrointestinal Endoscopy
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