REIMBURSEMENT POLICY MODERATE SEDATION POLICY Policy Number: ANESTHESIA 002.24 T0 Effective Date: April 1, 2016 Table of Contents Page APPLICABLE LINES OF BUSINESS/PRODUCTS…... APPLICATION……………........................................... OVERVIEW.................................................................. REIMBURSEMENT GUIDELINES............................... DEFINITIONS.............................................................. QUESTIONS AND ANSWERS.................................... ATTACHMENTS.......................................................... RESOURCES/REFERENCES..................................... POLICY HISTORY/REVISION INFORMATION........... 1 1 1 2 4 4 5 5 5 Related Policy: Supply Policy The services described in Oxford policies are subject to the terms, conditions and limitations of the Member's contract or certificate. Unless otherwise stated, Oxford policies do not apply to Medicare Advantage enrollees. Oxford reserves the right, in its sole discretion, to modify policies as necessary without prior written notice unless otherwise required by Oxford's administrative procedures or applicable state law. The term Oxford includes Oxford Health Plans, LLC and all of its subsidiaries as appropriate for these policies. Certain policies may not be applicable to Self-Funded Members and certain insured products. Refer to the Member's plan of benefits or Certificate of Coverage to determine whether coverage is provided or if there are any exclusions or benefit limitations applicable to any of these policies. If there is a difference between any policy and the Member’s plan of benefits or Certificate of Coverage, the plan of benefits or Certificate of Coverage will govern. APPLICABLE LINES OF BUSINESS/PRODUCTS This policy applies to Oxford Commercial plan membership. Note: While precertification is not required for moderate sedation, it may be required for the therapeutic and/or diagnostic procedures for which sedation is being provided. APPLICATION This reimbursement policy applies to services reported using the UB-04 claim form, the 1500 Health Insurance Claim Form (a/k/a CMS-1500), or their electronic equivalents or their successor forms. This policy applies to all network and non-network providers, including hospitals, ambulatory surgical centers, physicians and other qualified health care professionals including, but not limited to, non-network authorized and percent of charge contract physicians and other qualified health care professionals. OVERVIEW Current Procedural Terminology (CPT®) defines Moderate (conscious) Sedation as a drug induced depression of consciousness during which patients respond purposefully to verbal Moderate Sedation Policy: Reimbursement Policy (Effective 04/01/2016) ©1996-2016, Oxford Health Plans, LLC 1 commands, either alone or accompanied by light tactile stimulation. In addition, no interventions are required to maintain a patent airway and spontaneous ventilation is adequate. Cardiovascular function is usually maintained. Moderate Sedation does not include Minimal Sedation (anxiolysis), deep sedation, or monitored anesthesia care (CPT codes 00100-01999). Moderate Sedation services reported by the same physician, hospital, ambulatory surgical center, or other qualified health care professional reporting the diagnostic or therapeutic procedure, are separately reimbursable services when submitted under CPT codes 99143-99145 except when reported with the procedures noted below. In a facility setting, Moderate Sedation services performed by a second physician, hospital, ambulatory surgical center or other qualified health care professional are separately reimbursable services when submitted under CPT codes 99148-99150. In a non-facility setting, CPT codes 99148-99150 will not be reimbursed when the same physician, hospital, ambulatory surgical center or other qualified health care professional also reports a code listed in Appendix G of the CPT codebook. Note: Based on their intended use, Moderate Sedation codes 99148-99150 would not be reported with diagnostic or therapeutic procedures. Oxford's reimbursement policy for Moderate Sedation services is based on methodologies used and recognized by the Centers for Medicare and Medicaid Services (CMS) National Correct Coding Initiative (NCCI) edits and Policy Manual, and CPT codebook guidelines. For purposes of this policy, same physician, hospital, ambulatory surgical center or other qualified health care professional is defined as the same physician, hospital, ambulatory surgical center or other qualified health care professional rendering health care services reporting the same Federal Tax Identification number. REIMBURSEMENT GUIDELINES Attending Physician (99143-99145) Oxford will allow separate reimbursement for Moderate Sedation services reported as CPT codes 99143-99145 when provided by the Same Physician, hospital, ambulatory surgical center, or other qualified health care professional reporting the diagnostic or therapeutic procedure except when reported with: 1. Procedures listed in Appendix G of the CPT book 2. Anesthesia procedures (CPT codes 00100-01999) 3. CPT and HCPCS codes that are part of CMS NCCI edits These procedures include Moderate Sedation as an inherent part of providing the service. Refer to the list below for a comprehensive listing of the non-anesthesia procedures that include Moderate Sedation and for which CPT codes 99143-99145 will not be considered separately. Procedures that include Moderate Sedation codes (99143-99145) Note: Procedure codes that are listed in Appendix G of the CPT book that are also identified on the National Physicians Fee Schedule (NPFS) as Status B are addressed in the B Bundle Codes Policy. Second Physician (99148-99150) Moderate Sedation services performed by a second physician, hospital, ambulatory surgical center, or other qualified health care professional (who is not performing the diagnostic or therapeutic procedure that the sedation supports), should be reported as CPT codes 9914899150. Reimbursement of CPT codes 99148-99150 based on the place of service is as follows: Moderate Sedation Policy: Reimbursement Policy (Effective 04/01/2016) ©1996-2016, Oxford Health Plans, LLC 2 Non-facility setting According to the AMA “When moderate sedation is performed in the non-facility setting, the efforts of the second physician are not reported with the codes in Appendix G because moderate sedation is included in these codes. Therefore, it would not be appropriate to separately report for moderate sedation.” Based on AMA guidelines, Oxford will reimburse CPT codes 99148-99150 in a non-facility setting except when a procedure code listed in Appendix G of the CPT codebook is also reported on the same date of service by the same physician or other qualified health care professional. Facility setting Moderate Sedation services reported as CPT codes 99148-99150 that are performed by a second physician, hospital, ambulatory surgical center, or other qualified health care professional in a facility place of service (see listing below) are eligible for reimbursement. For purposes of this policy a facility place of service would include any of the following locations: 19 Off Campus-Outpatient Hospital 21 Inpatient Hospital 22 On Campus-Outpatient Hospital 23 Emergency Room-Hospital 24 Ambulatory Surgical Center 26 Military Treatment Facility 31 Skilled Nursing Facility 34 Hospice 41 Ambulance - Land 42 Ambulance - Air or Water 51 Inpatient Psychiatric Facility 52 Psychiatric Facility - Partial Hospitalization 53 Community Mental Health Center 56 Psychiatric Residential Treatment Center 61 Comprehensive Inpatient Rehabilitation Facility For additional information, refer to the Questions and Answers section, Q&A #1 and #3. Drug Reimbursement The cost of the drug used in Moderate Sedation, if supplied by the physician in a location other than inpatient/outpatient hospital, emergency room or ambulatory surgical center, is reimbursable at the appropriate fee schedule or contracted rate. For additional information on drugs supplies in an inpatient/outpatient hospital, emergency room or ambulatory surgical center, refer to the Supply Policy. ® The Current Procedural Terminology (CPT ) codes and Healthcare Common Procedure Coding System (HCPCS) codes listed in this policy are for reference purposes only. Listing of a service code in this policy does not imply that the service described by this code is a covered or noncovered health service. Coverage is determined by the member specific benefit document and applicable laws that may require coverage for a specific service. The inclusion of a code does not imply any right to reimbursement or guarantee claims payment. Other policies and coverage determination guidelines may apply. This list of codes may not be all inclusive. ® CPT Code 99143 Description Moderate sedation services (other than those services described by codes 00100-01999) provided by the same physician 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 patients level of consciousness and physiological status; under 5 years of age, first 30 minutes intra-service time Moderate Sedation Policy: Reimbursement Policy (Effective 04/01/2016) ©1996-2016, Oxford Health Plans, LLC 3 ® CPT Code 99144 99145 99148 99149 99150 Description Moderate sedation services (other than those services described by codes 00100-01999) provided by the same physician 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 patients level of consciousness and physiological status; age 5 years or older, first 30 minutes intra-service time Moderate sedation services (other than those services described by codes 00100-01999) provided by the same physician 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 patients level of consciousness and physiological status; each additional 15 minutes intra-service time (List separately in addition to code for primary service) Moderate sedation services (other than those services described by codes 00100-01999), provided by a physician other than the health care professional performing the diagnostic or therapeutic service that the sedation supports; under 5 years of age, first 30 minutes intra-service time Moderate sedation services (other than those services described by codes 00100-01999), provided by a physician other than the health care professional performing the diagnostic or therapeutic service that the sedation supports; age 5 years or older, first 30 minutes intra-service time Moderate sedation services (other than those services described by codes 00100-01999), provided by a physician other than the health care professional performing the diagnostic or therapeutic service that the sedation supports; each additional 15 minutes intra-service time (List separately in addition to code for primary service) CPT® is a registered trademark of the American Medical Association. DEFINITIONS Minimal Sedation: Minimal Sedation (anxiolysis) is 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. Moderate Sedation: Moderate (conscious) Sedation is a drug induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained. Moderate Sedation does not include Minimal Sedation (anxiolysis), deep sedation, or monitored anesthesia care (CPT codes 00100-01999). Same Physician, Hospital, Ambulatory Surgical Center, or Other Qualified Health Care Professional: The same physician, hospital, ambulatory surgical center or other qualified health care professional rendering health care services reporting the same Federal Tax Identification number. QUESTIONS AND ANSWERS Q1: A second physician has rendered Moderate Sedation in a non-facility setting for a procedure listed in Appendix G of the CPT codebook reported by the attending physician. Will the second physician’s services be separately reimbursed? A1: No. When Moderate Sedation is performed in the non-facility setting, the efforts of the second physician are not reported with the codes in Appendix G because Moderate Sedation is included in these codes. In a non-facility setting the second physician is considered the “trained observer,” and should be reimbursed by the attending physician. Moderate Sedation Policy: Reimbursement Policy (Effective 04/01/2016) ©1996-2016, Oxford Health Plans, LLC 4 Q2: In the policy overview it states: Moderate Sedation does not include Minimal Sedation (anxiolysis). What are some examples of Minimal Sedation? A2: According to the report titled Practice Guidelines for Sedation and Analgesia by NonAnesthesiologists (obtained from the ASA website), "Examples of minimal sedation include peripheral nerve blocks, local or topical anesthesia, and either (1) less than 50% nitrous oxide (N2O) in oxygen with no other sedative or analgesic medications by any route, or (2) a single, oral sedative or analgesic medication administered in doses appropriate for the unsupervised treatment of insomnia, anxiety, or pain." Q3: Why would it be appropriate to report CPT codes 99148-99150 for an Appendix G procedure when performed in a facility place of service? A3: According to the AMA, the provision of sedation by a second provider would not be the normal course of action and that implies a different intensity of work for these services than would be the case when it is inherent to the procedure. This work would properly be performed in a facility, not a non-facility, place of service. ATTACHMENTS Procedures that include Moderate Sedation Codes 99143-99145 This comprehensive list identifies the codes contained in Appendix G of the CPT book and codes that are part of CMS NCCI edits for procedures that include Moderate Sedation services. The codes on this list do not allow separate reimbursement for Moderate Sedation codes 99143-99145. RESOURCES/REFERENCES The foregoing Oxford policy has been adapted from an existing UnitedHealthcare national policy that was researched, developed and approved by UnitedHealthcare Payment Policy Oversight Committee. [2015R0035A] 1. Centers for Medicare and Medicaid Services, CMS Manual System and other CMS publications and services. 2. Centers for Medicare and Medicaid Services, National Correct Coding Initiative (NCCI) publications. 3. American Medical Association, Current Procedural Terminology (CPT®) and associated publications and services. 4. Publications and services of the American Society of Anesthesiologists (ASA). POLICY HISTORY/REVISION INFORMATION Date 04/01/2016 Action/Description Revised list of Procedures that include Moderate Sedation Codes 99143-99145 (attachment file detailing procedures that do not allow separate reimbursement for moderate sedation CPT codes 99143-99145): o Added 0394T, 0395T, 0424T, 0425T, 0426T, 0427T, 0428T, 0429T, 0430T, 0431T, 0432T, 0433T, 0434T, 0435T, 0436T, 43210, 45399, 61645, 77767, 77768, 77770, 77771 and 77772 o Removed 0387T, 0388T, 37217, 93355 and G0448 Archived previous policy version ANESTHESIA 002.23 T0 Moderate Sedation Policy: Reimbursement Policy (Effective 04/01/2016) ©1996-2016, Oxford Health Plans, LLC 5