GI Billing Classification

[2Fast2Des]

So Medicare and insurance companies don't seem to want to pay for healthy patients with no significant comorbidities, that sedation administered under by the proceduralists is acceptable in place of an anesthesiologist. How is this allowed\logical?

Do you guys classify GI cases as MAC or general? And does this make a difference in claim acceptance? I hate how we are told to classify as MAC, which no proceduralist or any one in the OR actually knows what it means, since we are basically doing a general without an airway.

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[Iso4ane]

Is a reimbursement on a MAC RVU less than and GA RVU? I thought they were comparable.

 

[dannyboy1]

Was told by the billing people that for ASA 2 or lower you only get reimbursed for MAC if there is documented obesity, OSA, documented difficult airway. For ASA 3 or greater you get reimbursed for MAC. For general anesthesia you get reimbursed regardless because by definition a patient getting GA needs an anesthesiologist present. Because of this we have been “encouraged” to document as GA whenever we use propofol because you probably went into GA at some point...

 

[2Fast2Des]

Is a reimbursement on a MAC RVU less than and GA RVU? I thought they were comparable.

I think the same, but would we be less likely be denied as a general vs mac?

 

[nimbus]

On the west coast, we have never done anesthesia for routine uncomplicated GI cases.

 

[2Fast2Des]

Was told by the billing people that for ASA 2 or lower you only get reimbursed for MAC if there is documented obesity, OSA, documented difficult airway. For ASA 3 or greater you get reimbursed for MAC. For general anesthesia you get reimbursed regardless because by definition a patient getting GA needs an anesthesiologist present. Because of this we have been “encouraged” to document as GA whenever we use propofol because you probably went into GA at some point...

We have been told the opposite, that you'd be "that guy" if you are an outlier billing general while everyone else tows the MAC line, which I guess would open up to audit?

I wonder then, for healthy patients we don't get reimbursed? How do anesthesiologists working in a surgicenter survive if you're dealing with healthy people all day?

 

[kidthor]

Because of this we have been “encouraged” to document as GA whenever we use propofol because you probably went into GA at some point...

I always bill it at GA because it's always GA.

 

[deleted162650]

On the west coast, we have never done anesthesia for routine uncomplicated GI cases.

We do a fair bit.

GA and MAC bills at same rate. As far as approval goes, we just have the GI fill out a medical necessity form (box check) stating what condition the patient has that necessitates our services.

 

[IlDestriero]

I think MAC stands for rooM Air general with an unseCured airway.

 

[IlDestriero]

I think MAC stands for rooM Air general with an unseCured airway.

It should be RAG. Which is actually kind of fitting.

 

[deleted162650]

It should be RAG. Which is actually kind of fitting.

I call it a MAC-eral. It’s good when prepared correctly, but it gets veeeery fishy when poorly executed.

 

[Shimmy8]

I call it a MAC-eral. It’s good when prepared correctly, but it gets veeeery fishy when poorly executed.

Or because the patient looks like a damn dead fish out of water not breathing.

 

[abolt18]

So Medicare and insurance companies don't seem to want to pay for healthy patients with no significant comorbidities, that sedation administered under by the proceduralists is acceptable in place of an anesthesiologist. How is this allowed\logical?

Do you guys classify GI cases as MAC or general? And does this make a difference in claim acceptance? I hate how we are told to classify as MAC, which no proceduralist or any one in the OR actually knows what it means, since we are basically doing a general without an airway.

So document it as a GA with nasal cannula.

 

[B-Bone]

medicare changed their stance on anesthesia for routine endoscopy in 2014, and most payors followed suit. Prior to that, medicare and most payors required patients to meet certain criteria to pay for anesthesia (ASA3, documented anxiety disorder, failed scope under RN sedation, etc). This article provides a nice summary of the current situation:

Anesthesia for Endoscopy: Economics 101 | Anesthesia Business Consultants

 

[nimbus]

We do a fair bit.

GA and MAC bills at same rate. As far as approval goes, we just have the GI fill out a medical necessity form (box check) stating what condition the patient has that necessitates our services.

You do ASA 1s and 2s? What do you use for medical necessity? Anxiety disorder?

 

[deleted126335]

I call it a MAC-eral. It’s good when prepared correctly, but it gets veeeery fishy when poorly executed.

Big Mac - Wikipedia

en.m.wikipedia.org

 

[deleted162650]

You do ASA 1s and 2s? What do you use for medical necessity? Anxiety disorder?

The GIs are the ones that fill out the form.
Anxiety is a common one. Other popular indications in the ASA 1-2 crowd include: history of substance/EtOH use, prior attempt at procedure unsuccessful without anesthesia, hypertensive heart disease, metabolic disorder (hypothyroid or controlled DM), and even “screening colonoscopy” is an indication for some reason.

 

[nimbus]

The GIs are the ones that fill out the form.
Anxiety is a common one. Other popular indications in the ASA 1-2 crowd include: history of substance/EtOH use, prior attempt at procedure unsuccessful without anesthesia, hypertensive heart disease, metabolic disorder (hypothyroid or controlled DM), and even “screening colonoscopy” is an indication for some reason.

We provide anesthesia for many of the same indications but it’s usually 1 or 2 cases in a lineup of 8-10. The rest the patients get sedation by the nurse. We never do the whole list.

 

[anbuitachi]

i dont know about billing but i remember putting General as case type when i do my endoscopies.. because they are technically general cases without a tube.

Also ive heard several GI people say they prefer to have us there and use propofol because it provides 'better conditions'

in my previous hospital every endo/colon gets anesthesiologist

now at current hospital on east coast they are all done by nurse giving sedation. i wonder how much they give for a endoscopy and how long it takes to provide sedation before procedure start. i remember 1 instance in the past year where we were paged stat to teh endoscopy room because the patient kept on moving even after 4 of midaz and 250 of fentanyl given by nurse. they 'requested propofol'.

 

[Zekchar]

This came up at a buddy of mines institution. They do lots of endo / colons with 3:1 CRNA:Attending ratios. They were instructed by the department heads to call it MAC. I personally believe it is a general anesthetic but I wasn't asked. Case closed.

 

[cchoukal]

It’s certainly a GA when the scope is inserted.

 

[axeon123]

Side question since we're talking about big mac. For EGD in a patient with poorly controlled GERD/reflux, do you tend to lean towards GA (tube) or MAC?

 

[UscGhost]

Side question since we're talking about big mac. For EGD in a patient with poorly controlled GERD/reflux, do you tend to lean towards GA (tube) or MAC?

MAC.

Only consider doing geta in patients with food impaction, massive GI bleed, maybe a couple other rare scenarios

Depends a bit on how skilled your GI docs are. Havent intubated a GI case in 6 years

 

[2Fast2Des]

Side question since we're talking about big mac. For EGD in a patient with poorly controlled GERD/reflux, do you tend to lean towards GA (tube) or MAC?

GA with unprotected airway

 

[Arch Guillotti]

GA with unprotected airway

Same here. Will never understand how an egd is considered a “mac”.

 

[AdmiralChz]

It’s mostly semantics, but calling it a MAC (versus a general) allows our GI RNs to recover the patients themselves versus head to PACU. If it’s checked “General” that would crush the workflow at our hospitals. These folks are of course awake and oriented faster than your typical GA in the OR, that makes a huge difference in recovery.

it was my understanding that certain states / insurance carriers require the medical necessity form. Mine doesn’t, but we do the form anyway. That also might be old news - to my knowledge we never have trouble billing in GI. But we only do about 10% or so ASA 1s and 2s.

As far as intubations, NEVER for severe GERD (a frequent EGD indication) alone. As above said - food bolus (if it’s upper obstruction, and you know!), some ERCPs (doc preference), and odd-ball advanced endoscopies (Spirus enteroscopy sometimes, pancreatic necrosectomies).

Also of note - I don’t work at a place with a GI fellowship. We intubated many more endoscopies in residency for this reason. Our docs here are all pretty slick.

 

[jwk]

It’s mostly semantics, but calling it a MAC (versus a general) allows our GI RNs to recover the patients themselves versus head to PACU. If it’s checked “General” that would crush the workflow at our hospitals. These folks are of course awake and oriented faster than your typical GA in the OR, that makes a huge difference in recovery.

GI RNs should be able to handle GA patients. We do many of our ERCPs under GA - they stay in the GI PACU.

 

[AdmiralChz]

GI RNs should be able to handle GA patients. We do many of our ERCPs under GA - they stay in the GI PACU.

Should. The Pre/Post GI area is not allowed to take post-general cases due to ratios as the nurses float around and aren’t 1:2.

 

[dhb]

A vast majority of colonoscopies (and a fair number of EGDs) in Belgium or France are done under propofol anesthesia.
In Belgium a colonoscopy is paid 140,9e and an EGD 88,6 (you only get to bill for 1 of the procedures even if they do both)

 

[vector2]

Also of note - I don’t work at a place with a GI fellowship. We intubated many more endoscopies in residency for this reason. Our docs here are all pretty slick.

Ahh, you're living the dream.