DS OR GA (with no gag, lid reflex, jaw thrust)

[turnupthevapor]

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If this has already been discussed please let me know....What is the general consensus for the type of anesthesia billed for EGD/Colonsocopy when propofol is administered until there is a loss of lid reflex and no response to painful stimuli (i.e. jaw thrust), gag is lost for the majority of the procedure as in EGD?

After reviewing the ASA's statement which was updated in 2014, it seems it should be GA although interpretation can be tough......My patients do not respond purposefully during my colonoscopy sedation which is one of the criteria set forth by the ASA in their definition for Deep Sedation.

We could extend the debate further to prostate biopsies and the like which I titrate my propofol to the same endpoint.

 

[twoliter]

If this has already been discussed please let me know....What is the general consensus for the type of anesthesia billed for EGD/Colonsocopy when propofol is administered until there is a loss of lid reflex and no response to painful stimuli (i.e. jaw thrust), gag is lost for the majority of the procedure as in EGD?

After reviewing the ASA's statement which was updated in 2014, it seems it should be GA although interpretation can be tough......My patients do not respond purposefully during my colonoscopy sedation which is one of the criteria set forth by the ASA in their definition for Deep Sedation.

We could extend the debate further to prostate biopsies and the like which I titrate my propofol to the same endpoint.

Sounds pretty clear that it meets the definition of general anesthesia (if they have no response to painful stimuli). But you may want to reword your poll. You are asking a question for us to pick between two options (GA or DS), but your answer choices are Yes and No -- unless we just say "yes, it is one of those two."

 

[soorg]

The ASA and the insurance companies always make this an issue, when it's plain and simple. Another classic example of suits making things unnecessarily complicated. As a public service to the free world, I will solve this problem right now:

MAC: We just check vital signs. Maybe give oxygen.

Conscious Sedation: Versed, +/- Fentanyl

Deep Sedation: Anything involving Propofol but without an LMA or ETT.

GA: Sevo/Des.

Next case.

 

[Noyac]

^^^try again.

 

[turnupthevapor]

Sounds pretty clear that it meets the definition of general anesthesia (if they have no response to painful stimuli). But you may want to reword your poll. You are asking a question for us to pick between two options (GA or DS), but your answer choices are Yes and No -- unless we just say "yes, it is one of those two."

thank you

 

[Mman]

The ASA and the insurance companies always make this an issue, when it's plain and simple. Another classic example of suits making things unnecessarily complicated. As a public service to the free world, I will solve this problem right now:

MAC: We just check vital signs. Maybe give oxygen.

Conscious Sedation: Versed, +/- Fentanyl

Deep Sedation: Anything involving Propofol but without an LMA or ETT.

GA: Sevo/Des.

Next case.

Huh? The billing rate for MAC or GA is identical. It doesn't matter to insurance companies where you draw the line.

 

[turnupthevapor]

Huh? The billing rate for MAC or GA is identical. It doesn't matter to insurance companies where you draw the line.

I have been told some some carriers are not reimbursing for conscious sedation/mac/DS if submitted (unless submitting codes for CHF, or other severe illness) only when GA is billed for. I have previously submitted DS but after reviewing the ASA definitions its seems I should have submitted GA all these years.

 

[deleted162650]

Dude, pretty simple: no response to painful stimuli = GA. Bills at the same rate regardless like Mman said although many carriers do request a "medical necessity" form to be completed by the GI doc to justify the need for Anesthesia presence or they try not to pay you.

 

[caligas]

The real question is what are the medico legal implications of taking a patient with poorly controlled GERD having an EGD and doing GA (propofol) without a secured airway.

 

[urge]

The real question is what are the medico legal implications of taking a patient with poorly controlled GERD having an EGD and doing GA (propofol) without a secured airway.

You are one of those that tubes everyone in endo, I suppose.

It drives everyone nuts. At my place they are not allowed anymore.

 

[caligas]

You are one of those that tubes everyone in endo, I suppose.

It drives everyone nuts. At my place they are not allowed anymore.

No, I do what most of us do: give the propofol and wait for them to get the scope down fast and suction out the stomach. Never had an issue but it stresses me out a bit.

You are right that everyone gets upset about partners that intubate for endo cases.

 

[urge]

No, I do what most of us do: give the propofol and wait for them to get the scope down fast and suction out the stomach. Never had an issue but it stresses me out a bit.

You are right that everyone gets upset about partners that intubate for endo cases.

Despite all their fear mongering nobody aspirates.

 

[Mman]

Despite all their fear mongering nobody aspirates.

well that's not true

 

[sleepallday]

You are one of those that tubes everyone in endo, I suppose.

It drives everyone nuts. At my place they are not allowed anymore.

What about the out patient ERCP done in the prone position? I tube them everytime regardless of many eye rolls i get.

 

[caligas]

What about the out patient ERCP done in the prone position? I tube them everytime regardless of many eye rolls i get.

I think the argument is more about EGD with propofol with patients that have some risk factors for aspiration. Most of us do it because it has come to be expected by many GI docs. Using lighter sedation or intubating are the alternatives, but will result in unsatisfied patients and staff. Fortunately aspiration is rare, but it happens.

 

[urge]

What about the out patient ERCP done in the prone position? I tube them everytime regardless of many eye rolls i get.

I do the same. Those patients are super sick and they all puke. Plus, the intubation/extubation doesn't take longer than the procedure.

 

[Arch Guillotti]

You are one of those that tubes everyone in endo, I suppose.

It drives everyone nuts. At my place they are not allowed anymore.

Even gastric outlet obstruction?

 

[urge]

Even gastric outlet obstruction?

If no NG and puking recently, probably tube them. I would use my best judgement.

 

[WholeLottaGame7]

The ASA and the insurance companies always make this an issue, when it's plain and simple. Another classic example of suits making things unnecessarily complicated. As a public service to the free world, I will solve this problem right now:

MAC: We just check vital signs. Maybe give oxygen.

Conscious Sedation: Versed, +/- Fentanyl

Deep Sedation: Anything involving Propofol but without an LMA or ETT.

GA: Sevo/Des.

Next case.

You sound like a surgeon.

 

[Noyac]

The airway has nothing to do with whether it's a MAC or GA. Obviously, if an LMA or ETT is in place then it's a GA but it doesn't go the other way. Meaning that if the airway is unprotected then it's not automatically a MAC. I worked with a very efficient plastic surgeon years ago. I would induce the pt, mask them for a minute and then strap the mask to their face and let them breath spontaneously without any airway device. It was a full GA.

 

[Noyac]

This is a simple distinction. It's not that difficult.

 

[YGK]

GA to me is when I need to control breathing mask ventilation, LMA, tube . If I am giving propofol and pt is breathing without assistant I call it MAC no matter how deep.

 

[Random Anesthesiologist]

The ASA is pretty clear on sedation levels.


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[jwk]

The real question is what are the medico legal implications of taking a patient with poorly controlled GERD having an EGD and doing GA (propofol) without a secured airway.

None from a billing standpoint.

 

[Noyac]

GA to me is when I need to control breathing mask ventilation, LMA, tube . If I am giving propofol and pt is breathing without assistant I call it MAC no matter how deep.

Then you are not understanding the difference.

 

[Ronin786]

They clarified this in their most recent update. If at any point during the case they're not responsive to noxious stimuli it's GA. Clear cut and dry. Airway has nothing to do with it. The wording for airway and cardiovascular stability all have leeway, the consciousness level is the only thing with clear distinctions.

 

[turnupthevapor]

GA to me is when I need to control breathing mask ventilation, LMA, tube . If I am giving propofol and pt is breathing without assistant I call it MAC no matter how deep.

That is not congruent with the ASA consensus statement that is in my post. will you conceed that your definition is inaccurate? thoughts?

 

[Arch Guillotti]

You are one of those that tubes everyone in endo, I suppose.

It drives everyone nuts. At my place they are not allowed anymore.

If no NG and puking recently, probably tube them. I would use my best judgement.

 

[fakin' the funk]

I like this forum and all, but this thread is so full of misinformation and misplaced confidence I don't know where to begin.

I will solve this problem right now:
MAC: We just check vital signs. Maybe give oxygen.
Conscious Sedation: Versed, +/- Fentanyl
Deep Sedation: Anything involving Propofol but without an LMA or ETT.
GA: Sevo/Des.

WRONG

The real question is what are the medico legal implications of taking a patient with poorly controlled GERD having an EGD and doing GA (propofol) without a secured airway.

That's not the "real" question. It's not even a good question.

You are one of those that tubes everyone in endo, I suppose. It drives everyone nuts. At my place they are not allowed anymore.

Any person, anesthesiologist or otherwise, who gets "driven nuts" by other anesthesiologists choosing airway instrumentation, can eat a bowl of d*cks.

Despite all their fear mongering nobody aspirates.

I bet someone aspirates.
Aspiration is, generally speaking, quite rare.
Probably more common in GI/endo than anywhere else though.

What about the out patient ERCP done in the prone position? I tube them everytime regardless of many eye rolls i get.

Sounds reasonable. Again, tell those eye rollers to eat a bowl of d*cks.

If no NG and puking recently, probably tube them. I would use my best judgement.

Would you?

GA to me is when I need to control breathing mask ventilation, LMA, tube . If I am giving propofol and pt is breathing without assistant I call it MAC no matter how deep.

WRONG
Fortunately you don't get to make these decisions. Our society (ASA) does. Call it what you want, but that's GA bro.

 

[urge]

I bet someone aspirates.
Aspiration is, generally speaking, quite rare.
Probably more common in GI/endo than anywhere else though.

How many patients undergoing EGD have you seen (or have direct knowledge) aspirate?

I only know of 1 and it was done by one of our quadruple boarded CCM/Anesthesia "Gurus" with more fellowships than IQ.

 

[OB1🤙]

This thread is pretty much full-blown AIDS, and is an embarrassment to our specialty.

 

[WholeLottaGame7]

This thread is pretty much full-blown AIDS, and is an embarrassment to our specialty.

Seriously. Of all the threads to delete, could the OP delete this one?

 

[jwk]

OK - I don't do billing so someone enlighten me - but, from a BILLING standpoint which was the OP's question, does GA or MAC make any difference? You're billing for the same procedure.

 

[CopaceticOne]

OK - I don't do billing so someone enlighten me - but, from a BILLING standpoint which was the OP's question, does GA or MAC make any difference? You're billing for the same procedure.

The point was just because you bill it doesn't mean it gets paid. It is harder to deny a GA bill than DS bill from an anesthesiologist. Just because you do the work doesn't mean that it will get paid unless it is coded properly.

 

[soorg]

The only bowlful of anything that I eat are Cheerios.

 

[chfo]

Anesthesia is a spectrum. How the anesthesia continuum chart is interpreted is subjective.

I define unarousable to noxious stimulation as an endotracheal tube inside an "asleep" nonparalyzed nontopicalized patient's trachea without movement. If your "asleep" nonparalyzed nontopicalized patient can get a tube placed and the patient does not move at all, whether purposeful or just bucking, then you're definitely fully and completely in general anesthesia. Anything lighter than that is a relative assessment dependent on personal interpretation.


Try these interesting questions: is it possible to do flexible bronchoscopy with biopsy under MAC? Or does the definition of a smooth movementless bronchoscopy necessitate calling the anesthesia general because the patient does not buck?

What about performing a procedure where the airway is secure with a tube but the patient is only in deep sedation? Would you still call this general or just MAC?

Is nonpourposeful movement anything which is not mediated by spinal or brainstem reflexes? Don't certain spinal reflexes occur without cortical input?

 

[OB1🤙]

The very definition of minimum alveolar concentration involves half of patients moving at a MAC of 1.

Arousability has precisely nothing to do with movement in response to a noxious stimulus.

 

[Random Anesthesiologist]

I've seen tons of people with ETTs in the OR and unit under sedation who can be roused and responsive. It is not subjective, there are consensus guidelines by the ASA, and we are tested on them in training and boards. The ETT does not define the level.

http://www.asahq.org/~/media/Sites/...esthesia-and-levels-of-sedation-analgesia.pdf

 

[pjl]

It is clear what is defined as a General anesthetic by the ASA. The only issue comes in how to convince guys who have been calling anything without an artificial airway a MAC for 30 years to change their way of thinking. Change is tough.

I was accused of malpractice by one of those people when I asked that we have a way to document a plan for anesthesia as General with natural oriface airway, and was told this should never occur as a plan. They felt that legally, by planning sedation to the point of loss of airway reflexes if you did not either insert an airway or lighten sedation, you were engaging in malpractice. So I am stuck without the ability to document this easily in the EMR.

Do you guys document this as a plan? I just see that documentation as being honest about your intent, and appropriate based on the sedation scale published by ASA.


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[jwk]

It is clear what is defined as a General anesthetic by the ASA. The only issue comes in how to convince guys who have been calling anything without an artificial airway a MAC for 30 years to change their way of thinking. Change is tough.

I was accused of malpractice by one of those people when I asked that we have a way to document a plan for anesthesia as General with natural oriface airway, and was told this should never occur as a plan. They felt that legally, by planning sedation to the point of loss of airway reflexes if you did not either insert an airway or lighten sedation, you were engaging in malpractice. So I am stuck without the ability to document this easily in the EMR.

Do you guys document this as a plan? I just see that documentation as being honest about your intent, and appropriate based on the sedation scale published by ASA.


Sent from my iPad using SDN mobile app

Maybe some get their MAC cases a whole lot deeper than we do - I don't know. Most of our GI cases are well into the deep sedation range. They breathe spontaneously, I rarely need to support an airway. A nice jaw thrust rouses pretty much all of them. As the saying goes, anesthesia is a continuum. Might they drift down into GA for a few moments? Maybe. If they do, lighten up and they'll drift back up into the deep sedation range. The plan is not "MAC but might turn into GA if I give too much". The plan is not to keep them towards the GA side of deep sedation vs GA. Every case we do, even with spinals and blocks, is a potential GA. But the "plan" is a MAC. There's no intent to get them past the deep sedation stage.

 

[periopdoc]

This thread is a patent embarrassment.

It doesn't matter what you feel or personally define as GA. It's written out in black and white in the ASA guidelines and billing book.

I would be a hell of a lot more nervous being sued for a adverse outcome when I knowingly mis-classified a GA as a MAC or a sedation. I would much rather defend my judgement for why I thought a GA without controlled airway was appropriate for a specific patient, than try to defend against accusations of fraudulent documentation.


-pod

 

[CopaceticOne]

The very definition of minimum alveolar concentration involves half of patients moving at a MAC of 1.

Arousability has precisely nothing to do with movement in response to a noxious stimulus.

MAC is referring to monitored anesthesia care in this thread.

 

[Mman]

there is no requirement that you continually document the patient's level of responsiveness during the procedure. You document a plan of GA or MAC and you bill for one or the other, but on a chart you don't have to check a box or click a button every 5 minutes that mentions they are still maintaining airway reflexes. Probably part of the reason why reimbursement rates are identical for the 2. It is a continuum and it doesn't matter financially which side you are on.

 

[OB1🤙]

MAC is referring to monitored anesthesia care in this thread.

Obviously. I was responding to the post above mine. My point was that a patient moving in response to stimulus cannot possibly be incorporated in the definition of GA vs deep sedation- because at a MAC of 1 under inhaled volatile anesthesia, half of patients would move BY DEFINITION unless they were paralyzed.

 

[chfo]

Obviously. I was responding to the post above mine. My point was that a patient moving in response to stimulus cannot possibly be incorporated in the definition of GA vs deep sedation- because at a MAC of 1 under inhaled volatile anesthesia, half of patients would move BY DEFINITION unless they were paralyzed.

Which is why it's a bull**** claim that the ASA sedation guidelines are black and white.

Everybody knows that patients will move if you do surgery on normals at an inhalation mac of 0.3, but nobody would claim that this is now deep sedation just because of how the guidelines define GA vs DS.

 

[Arch Guillotti]

How many patients undergoing EGD have you seen (or have direct knowledge) aspirate?

At least one.

 

[soorg]

Again,

MAC: We just check vital signs. Maybe give oxygen.
Conscious Sedation: Versed, +/- Fentanyl
Deep Sedation: Anything involving Propofol but without an LMA or ETT.
GA: Sevo/Des.

Don't make a simple issue complicated. There's no need.

 

[Arch Guillotti]

Again,

MAC: We just check vital signs. Maybe give oxygen.
Conscious Sedation: Versed, +/- Fentanyl
Deep Sedation: Anything involving Propofol but without an LMA or ETT.
GA: Sevo/Des.

Don't make a simple issue complicated. There's no need.

So a young healthy patient receiving 5 mcg/kg/min of propofol is deep sedation?

 

[Urzuz]

Again,

MAC: We just check vital signs. Maybe give oxygen.
Conscious Sedation: Versed, +/- Fentanyl
Deep Sedation: Anything involving Propofol but without an LMA or ETT.
GA: Sevo/Des.

Don't make a simple issue complicated. There's no need.

This is just flat out wrong though. I understand some people above have been discussing how a lot of the definitions aren't clear cut and may be on a continuum, which I get...but your definitions are just flat wrong. This isn't even an argument. Open up a textbook and you will see that it's simply incorrect.

Depth of sedation definitions are NOT defined by presence or absence of an airway, and NOT by what drugs are being given.

Read this: http://www.asahq.org/~/media/Sites/...esthesia-and-levels-of-sedation-analgesia.pdf

And before you say that you define it differently and it's open to interpretation, realize that you are using words and lingo (deep sedation, MAC, GA, etc) that have very specific definitions, and mean very specific things to an anesthesiologist. You can't pick and choose how to define them. It's like me telling you that I believe a heart rate of 80 is bradycardic and that the definition is open to interpretation. You can't show me any hard "physical proof" that a HR of 80 isn't bradycardia. All you can do is show me what other people define bradycardia as. But that definition means something to people in the hospital, and you can't just invent your own definition because you feel like it. To carry the analogy further, imagine a cardiologist saying that a heart rate of 80 is bradycardia. That's embarrassing, right? This is akin to this situation.

 

[OB1🤙]