574coding

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Hello,
How do you handle the medical necessity for anesthesia on a procedure that per the LCD, anesthesia is not routinely necessary for the procedures? I think our office needs to have a form or something that documents the reason anesthesia is required for the procedure. Does any one have any ideas or can share verbiage with me?
Thank you
 
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203
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Hi there,

The diagnosis code for the condition that made anesthesia medically necessary may be enough. In the case of very young pediatric patients the patient's age may be enough. But I'm hearing that it is becoming the norm for payers to deny automatically and require an appeal. That's why the anesthesia provider should document exactly why the patient needs anesthesia care. "The patient is 2 years old and unable to understand or follow instructions." "Due to [the patient's medical condition] patient cannot hold still for the duration of the procedure." "The patient required monitored anesthesia care because the patient's history of [medical condition] placed them at greater risk for [bad thing] during the procedure. You will need that for your appeal. One other note - be careful if the reason is anxiety. It has to be more than the patient was nervous about having a medical procedure and at a level that couldn't be addressed with half a Valium or something.
 

SheaRa

New
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Springville, AL
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I have found with my Pain Doctor doing OBA ( MAC) that the payors want to see the co-morbidities' listed if the patient physical status is an ASA2-ASA6 (P2-P6).
 
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Albany
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We perform moderate sedation in office and at an ASC facility. I see that lately most insurances (especially Medicare) are denying sedation based on medical necessity. Policy states that it may be covered for certain circumstances so I try to have our providers order the sedation with the procedure and clearly state why it is being ordered. I also have thee reason documented in the procedure notes. I have been appealing the denials with this information but they are all still in review. Most of our patients have a anxiety/fear of needles. We do bill with F40.231 Fear of injections and transfusions as well.
 
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