Revenue Cycle Insider

Hint: Payers may define “medically necessary” differently for pediatric patients.

They are our favorite little people, and everyone wants to ensure that anesthesia services provided to pediatric patients are accurate and reflective of the services provided. What makes these patients special through the lens of billing for anesthesia services is that pediatric patients often qualify for anesthesia for procedures that adults do not qualify for, and this special distinction may also include adult patients with learning disabilities.

Many payer policies have exceptions for these special patients, and this article will highlight policy variables, as well as discuss the difference between moderate sedation, monitored anesthesia care (MAC), and general anesthesia, when a patient is put under and is not conscious.

Report Dental Anesthesia Services With Confidence

Often, terms and conditions can be confusing to coders who depend on the providers to document the correct type of anesthesia. Even something as simple as dental surgery may have coders scratching their heads when it comes to reporting services.

While the presence of a qualified anesthesia provider may not always be required for dental services, knowing what to look for when services are medically necessary comes in handy. Although one may expect that anesthesia codes could only be reported by trained anesthesia providers, there are policies indicating non-anesthesia providers would be paid for billing anesthesia codes under certain circumstances.

When providing anesthesia for dental services, payers may require dental codes are reported rather than anesthesia codes — even when general anesthesia is provided. For example, in their current policy, Molina Healthcare provides a list of covered dental codes when patients meet outlined criteria. In this example, an “extremely uncooperative, fearful, anxious or physically resistant child or adolescent with substantial dental needs and no expectation that the behavior will improve soon” who undergoes deep sedation or general anesthesia for 30 minutes would be reported with Current Dental Terminology (CDT^®) codes D9222 and D9223.

Conversely, if the same pediatric patient was covered by Aetna, its current policy requires CPT^® or American Society of Anesthesiologists (ASA) code 00170 with a base value of 5  units, plus 2 units of time. Aetna considers general anesthesia or MAC medically necessary for dental or oromaxillofacial surgery (OMS) for children up to and including 12 years old; members with physical, intellectual, or medically compromising conditions; and covered members who are “extremely uncooperative, fearful, unmanageable, anxious, or uncommunicative.”

Understanding there may be different requirements, depending on payer policies, to report these types of services on behalf of pediatric and adult patients who qualify, we look next at the differences in the types of anesthesia provided.

Understand MAC Specifications

MAC services are rendered by anesthesia providers who aren’t involved in the diagnostic or procedural service, and include the same care as any other anesthesia service: a pre-anesthesia assessment or evaluation (before anesthesia time starts and included in the base value), documentation of vital signs and patient monitoring during the procedure (during), and post-anesthesia patient care (after anesthesia time ends and included in the base value).

When MAC is the type of anesthesia, the anesthesia provider must be qualified to convert to a general anesthetic, which requires anesthesia training. In their Statement on Continuum of Depth of Sedation, the ASA defines MAC as “a specific anesthesia service performed by a qualified anesthesia provider, for a diagnostic or therapeutic procedure.” Indications for MAC include “the need for deeper levels of analgesia and sedation than can be provided by moderate sedation (including potential conversion to a general or regional anesthetic.”  

In the same continuum statement, ASA defines moderate sedation as “a drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation.” General anesthesia is defined as “drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation. The ability to independently maintain ventilatory function is often impaired. Patients often require assistance in maintaining a patent airway, and positive pressure ventilation may be required because of depressed spontaneous ventilation or drug-induced depression of neuromuscular function. Cardiovascular function may be impaired.”

See What Distinguishes Moderate Sedation

Moderate (conscious) sedation, as defined by the CPT^®, closely matches the ASA’s definition of a drug-induced depression of consciousness, further explaining that “No interventions are required to maintain cardiovascular function or a patent airway, and spontaneous ventilation is adequate.” CPT^® also indicates that moderate sedation codes “are not used to report administration of medications for pain control, minimal sedation (anxiolysis), deep sedation, or monitored anesthesia care,” sending coders to the anesthesia code ranges 00100 (Anesthesia for procedures on salivary glands, including biopsy) through 01999 (Unlisted anesthesia procedure(s)), which are found under the anesthesia section of the CPT^® code book.

Find Age-Specific Codes

Moderate sedation codes 99151 (Moderate sedation services 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 patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient younger than 5 years of age) through +99153 ( … each additional 15 minutes intraservice time (List separately in addition to code for primary service)) require the sedation service be provided by the same physician performing the diagnostic or therapeutic service, along with an independent trained observer to assist monitoring the patient.

On the other hand, codes 99155 (Moderate sedation services provided by a physician or other qualified health care professional other than the physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports; initial 15 minutes of intraservice time, patient younger than 5 years of age) through +99157 (… each additional 15 minutes intraservice time (List separately in addition to code for primary service)) require the sedation service be provided by a physician or other qualified healthcare professional other than the one performing the diagnostic or therapeutic services, and an independent trained observer is not required.

Rely On Time When Choosing Codes

In all cases, whether general, MAC, or moderate sedation, time is a factor for reporting anesthesia or sedation services. When reporting anesthesia codes, the documentation must clearly show pre- and post-anesthesia evaluation or assessment time as separate from the anesthesia time reported for the surgery. Intraservice time as outlined in CPT^® is reported for sedation services, and begins “with the administration of the sedating agent(s)” and ends “when the procedure is completed, the patient is stable for recovery status, and the physician or other qualified health care professional providing the sedation ends personal continuous face-to-face time with the patient.” Coders may receive documentation with a “sedation” or “intra-service sedation” record rather than an “anesthesia” record, which includes the previously mentioned pre- and post-anesthesia assessment or evaluation.

The ASA publishes several statements related to pediatric patients, as well as statements related to adult patients, and the granting of privileges that may be missed if you are just searching for the term “pediatric” in the ASA’s Statements and Practice Parameters. While insurance companies may not make a distinction between an anesthesiologist and non-anesthesiologist, the ASA recommends any practitioner who has been granted privileges to take care of pediatric patients has the training and life-support skills to safely treat our most vulnerable patients.

Kelly D. Dennis, MBA, ACS-AN, CANPC, CHCA, CPMA, CPC, CPC-I, Perfect Office Solutions