Contractor Name
HealthNow UMD

Contract Number
00801

Contractor Type
Carrier

LCD Database ID Number
L4261

LCD Title
Anesthesia for Anorectal Procedures

Contractor's Determination Number
AN003E02 End dated

AMA CPT Copyright Statement
CPT codes, descriptions, and other data only are copyright 2006 American Medical Association (or such other data 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 examinations.

   -   Title XVIII of the Social Security Act, Section 1862 (a)(1)(A)

       This section allows coverage and payment for only those services
       considered medically reasonable and necessary.

   -   Title XVIII of the Social Security Act, Section 1833 (e)

       This section prohibits Medicare payment for any claim which lacks the
       necessary information to process the claim.

   -   CMS Manual System, Pub 100-4, Chapter 12, Sections 50, 50K and
       140.3.2.

       These sections define payment guidelines for anesthesia services for
       physicians.

Oversight Region
Region II

CMS Consortium
Northeast

Original Determination Effective Date
For services performed on or after 05/16/2002

Original Determination Ending Date

Revision Effective Date
03/01/2007

Revision Ending Effective Date
03/28/2008

Indications and Limitations of Coverage and/or Medical Necessity
Patients undergoing anorectal surgical procedures may receive medications for anxiety, discomfort, and anesthesia, as well as monitoring during the procedure. The procedures involve the rectum and anus, and the anesthesia includes any endoscopy associated with these surgical procedures.

Indications

Delivery of anesthesia by an anesthesiologist/anesthetist for anorectal surgical procedures is indicated when such procedures are performed requiring more than local anesthesia. If the surgical procedure includes endoscopy, then the anesthesia for that endoscopy is also included in the anesthesia for the entire procedure. It may be indicated for diagnostic anoscopy/proctoscopy in cases of severe anal/rectal stenosis.

Limitations
The anesthesia code may not be used to code endoscopy, which is not a part of or related to the anorectal procedure, and performed at the same time.

It is anticipated that it would usually not be medically necessary for a patient to need anesthesia requiring the presence of an anesthesiologist/anesthetist for the performance of a diagnostic anoscopy or proctoscopy except in cases of severe anal stenosis.

Coverage Topic
Anesthesia (Inpatient)
Anesthesia (Outpatient)

CPT/HCPCS Codes

    00902           Anesthesia for anorectal procedure

Does the CPT 30% Coding Rule Apply?
No

ICD-9-CM 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 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 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" section of this LCD.

    078.10*         Viral warts unspecified

    078.11*         Condyloma acuminatum

    079.4*          Human papillomavirus in conditions classified
                    elsewhere

    154.1           Malignant neoplasm of rectum

    154.2           Malignant neoplasm of anal canal

    154.3           Malignant neoplasm of anus, unspecified

    154.8           Malignant neoplasm of rectum, rectosigmoid junction,
                    and anus; other

    173.5           Other malignant neoplasm of skin of trunk, except
                    scrotum

    211.4           Benign neoplasm of rectum and anal canal

    216.5           Benign neoplasm of skin of trunk, except scrotum

    455.0           Internal hemorrhoids without mention of complication

    455.1           Internal thrombosed hemorrhoids

    455.2           Internal hemorrhoids with other complication

    455.3           External hemorrhoids without mention of complication

    455.4           External thrombosed hemorrhoids

    455.5           External hemorrhoids with other complication

    455.6           Unspecified hemorrhoids without mention of
                    complication

    455.7           Unspecified thrombosed hemorrhoids

    455.8           Unspecified hemorrhoids with other complication

    455.9           Residual hemorrhoidal skin tags

    564.6           Anal spasm

    565.0           Anal fissure

    565.1           Anal fistula

    566             Abscess of anal and rectal regions

    569.0           Anal and rectal polyp

    569.1           Rectal prolapse

    569.2           Stenosis of rectum and anus

    569.3           Hemorrhage of rectum and anus

    569.41          Ulcer of anus and rectum

    569.42          Anal and rectal pain

    569.49          Other specified disorders of rectum and anus

    618.04*         Rectocele

    619.1*          Digestive-genital tract fistula female

    680.5           Carbuncle and furuncle; buttock

* ICD-9CM codes effective 07/18/2003

ICD-9-CM 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 LCD 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 operative report and record of anesthesia care must be maintained
       in the patient's medical record.

   3.  Documentation must be available to Medicare upon request.

Sources of Information and Basis for Decision

   1.  Memo from the CPT Editorial Board.

   -   This LCD was presented at the October 17, 2001 Carrier Advisory
       Committee meeting by Empire Medicare Services.

   -   This LCD does not reflect the sole opinion of the contractor or
       Contractor Medical Director.  Although the final decision rests with
       the carrier, this LCD was developed in cooperation with advisory
       groups, which includes representatives from the New York State Chapter
       of the American Society of Gastrointestinal Endoscopies and the New
       York State Society of Anesthesiologists.

End Date of Comment Period
12/02/2001

Start Date of Notice Period
03/28/2008

Revision History Number
1

Revision History Explanation
This LCD is end dated effective 03/28/2008.

Revision 2: Added ICD-9CM codes 078.10, 078.11, 079.4, 618.04 and 619.1 per a reconsideration request. They are effective for dates of service on and after 07/18/2003. Added up to date IOM reference and Copyright statement as well.

** 05/23/2005 - This LMRP was converted to a LCD only.

Revision 1: Revised on 05/30/2002 to add place of service, office (11), as a payable place of service. Also replaced first bullet under "Documentation Requirements."

Does this LCD contain a "Least Costly Alternative" provision?
No