March 2002
Volume 66 |
Number 3
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PRACTICE
MANAGEMENT
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| Sedation
and the Need for Anesthesia Personnel |
Karin Bierstein, J.D.
Assistant Director of Governmental Affairs (Regulatory)
Some hospitals are asking anesthesiology departments to cover locations
far away from the operating room. Endoscopy and magnetic resonance
imaging (MRI) suites as well as cardiac catheterization laboratories
are among those responsible for the “metastatic anesthesia”
phenomenon. Providing sedation/analgesia services for endoscopies,
MRIs, catheterizations and similar procedures potentially creates
two problems for anesthesiologists. First, the pervasive shortage
of anesthesia personnel means that surgical operations may be delayed
if anesthesiologists and nurse anesthetists are working at remote
locations. Second, Medicare (and conceivably the more aggressive
commercial payers) may deny payment on the grounds that anesthesia
for the endoscopy or radiology service is not “medically necessary.”
JCAHO Standards
The reason for many hospitals’ staffing requests and expectations
is the standards for “moderate or deep sedation and anesthesia”
adopted by the Joint Commission on Accreditation of Healthcare
Organizations (JCAHO). Beginning in 2001, significantly revised
anesthesia standards encompassed and defined sedation. The standards
do not govern “minimal sedation (anxiolysis) — 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.”
They do, however, apply to “moderate” or “conscious”
and “deep” sedation as well as to anesthesia.
These four levels of sedation were originally defined in the
ASA statement on “Continuum of Depth of Sedation” approved
by the ASA House of Delegates in 1999. The statement also specified,
“Because sedation is a continuum, it is not always possible
to predict how an individual patient will respond. Hence, practitioners
intending to produce a given level of sedation should be able
to rescue patients whose level of sedation becomes deeper than
initially intended.”
JCAHO adopted the definitions of the four levels almost verbatim.
The agency also incorporated in its standards the need to be able
to rescue patients from a deeper level of sedation. At least equally
importantly, JCAHO introduced a requirement for an additional
qualified individual to monitor the patient. This also appears
as a recommendation in ASA’s “Practice Guidelines for
Sedation and Analgesia by Nonanesthesiologists”:
“A designated individual, other than the practitioner
performing the procedure, should be present to monitor the patient
throughout procedures performed with sedation/analgesia. During
deep sedation, this individual should have no other responsibilities.
However, during moderate sedation, this individual may assist
with minor, interruptible tasks once the patient’s level
of sedation/analgesia and vital signs have stabilized, provided
that adequate monitoring for the patient’s level of sedation
is maintained.”
The intention behind ASA’s practice guidelines was to help
ensure patient safety by providing information for nonanesthesiologists
on, for example, the content of the presedation evaluation (abnormalities
of the major organ systems; drug allergies, current medications
and potential drug interactions, etc.) and on the need for an
individual other than the one performing the procedure to monitor
the patient constantly. Endorsement by organizations such as the
American Society for Gastrointestinal Endoscopy testifies to the
usefulness of the practice guidelines.
It is highly ironic that this document, cited in the JCAHO manual,
may now be misinterpreted and misused to require the participation
of anesthesia personnel in moderate sedation. The Committee on
Quality Management and Departmental Administration has received
a number of reports from ASA members about hospitals demanding
the presence of a member of the anesthesiology department in the
MRI or endoscopy suite.
Anesthesiologists often find it difficult to comply with the
hospital’s demand for coverage at locations far from the
operating room because they are already working to, or beyond,
capacity. The nationwide shortage of both anesthesiologists and
nurse anesthetists is well known. Working a 10-hour day is not
always a problem when patients truly need one’s services.
It is less attractive if reimbursement is uncertain — which
may happen if there are questions as to the medical necessity
for the anesthesia care.
Payment for Sedation
Medicare and some private payers do not pay for “conscious
sedation” as defined in Current Procedural Terminology (CPT™),
i.e., a service provided by the operating practitioner “requiring
the presence of an independent trained observer to assist the
physician in monitoring the patient’s level of consciousness
and physiological status.” The service normally performed
by anesthesiologists for endoscopy or imaging, in payment terms,
is monitored anesthesia care (MAC) rather than general anesthesia
or conscious sedation. Medicare will not pay for a MAC service
that is not medically necessary, and it does not consider hospital
or surgeon preference tantamount to medical necessity.
Some Medicare carriers have defined medical necessity according
to the surgical procedure and to the patient’s condition
or comorbidities. Certain procedures, endoscopies typically among
them, require a particular diagnosis in order for MAC to be deemed
necessary. The difference between MAC and general anesthesia is
not always clear; there is no established time interval during
which protective reflexes must be absent for the anesthesia to
qualify as “general.” The temptation to provide a level
of sedation that can be billed as “general anesthesia”
is obvious, although one hopes, of course, that patient care decisions
are driven by patient need rather than by reimbursement factors.
Free Services to the Hospital?
If the anesthesia service provided in the endoscopy suite is not
billable to Medicare because it is not medically necessary, who
should bear the cost?
Since hospital (or surgeon) convenience or preference is determining
the use of anesthesiologists or nurse anesthetists, the logical
payer would be the hospital or the physician performing the procedure.
Obtaining compensation from the surgeon is unlikely: A direct
payment could be considered fee-splitting, and a payment from
Medicare, offset by a corresponding reduction in the payment to
the surgeon, is not possible under the Medicare Fee Schedule structure
(as some New York anesthesiologists found out when they challenged
their carrier’s blanket policy that MAC is unnecessary for
endoscopy. See the discussion of the New York endoscopy saga in
the December 2001 issue of the NEWSLETTER).
The hospital, however, can and should reimburse the anesthesiologist
who provides a nonbillable service that benefits the hospital
(by obviating the need for hospital employees to monitor patients
undergoing conscious sedation; perhaps even by helping the hospital
market itself as a provider of the highest quality care). Indeed,
if the hospital is attempting to exact free services as the price
of the anesthesia group’s exclusive contract, there is at
least a technical violation of the federal antikickback statute.
While the Office of the Inspector General has given no indication
that it will step in when hospitals demand that anesthesiologists
provide an economic benefit in exchange for access to the hospital’s
Medicare or other federally insured patients, the principle is
important. Anesthesiologists should seek fair reimbursement for
services provided to the hospital — stipends for 24/7 availability
of obstetric anesthesia in a low-volume obstetric unit are not
uncommon — and providing nonbillable sedation to endoscopy
or MRI patients likewise results in a loss to the anesthesia practice
and a net advantage to the hospital.
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