IV Sedation CPT

[Asprin]

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I am performing all my ESI's in the hospital. What are the different areas that I can bill for this procedure (fluoroscopy, injections, sedation). I understand that we can now administer and bill for moderate sedation ourselves, is this true (cpt 99144)? What constitutes "moderate" sedation? How about 2mg Versed?

 

[Tenesma]

99144 does not include oral anxiolysis - definition is vague - patient needs to keep patent airway and be able to respond (somewhat) to stimuli...

i have a lot of patients who are coming to me specifically because they heard i don't use sedation... SURPRISE to me! ---- so i can't profit from this revenue stream.. 🙂

the real issue should be what is standard of care nationally (which is really no standard since some do and some don't) --- and what is best for your patients...

clearly the financial incentive is there to use sedation all the time especially if you are hospital based because you don't carry the burden of overhead

i know of a few practices that use propofol for all their procedures - but think about the complaints you will get of burning.... i know of a few practices that use sedation for ALL of their cases --- but think of those crazy patients who show up with an escort/driver only to find out later that the crazy patient actually drove the escort home after the procedure

i provided "moderate" sedation for 2 patients in 2007 --- all the rest who needed sedation got valium 5mg in the morning of the procedure...

am i under-sedating? based on hospital surveys of patient satisfaction 100% were happy (of those that sent back the surveys) so don't know if i would change my methods

anybody else have 2 cents to add?

 

[ampaphb]

99144 does not include oral anxiolysis - definition is vague - patient needs to keep patent airway and be able to respond (somewhat) to stimuli...

i have a lot of patients who are coming to me specifically because they heard i don't use sedation... SURPRISE to me! ---- so i can't profit from this revenue stream.. 🙂

the real issue should be what is standard of care nationally (which is really no standard since some do and some don't) --- and what is best for your patients...

clearly the financial incentive is there to use sedation all the time especially if you are hospital based because you don't carry the burden of overhead

i know of a few practices that use propofol for all their procedures - but think about the complaints you will get of burning.... i know of a few practices that use sedation for ALL of their cases --- but think of those crazy patients who show up with an escort/driver only to find out later that the crazy patient actually drove the escort home after the procedure

i provided "moderate" sedation for 2 patients in 2007 --- all the rest who needed sedation got valium 5mg in the morning of the procedure...

am i under-sedating? based on hospital surveys of patient satisfaction 100% were happy (of those that sent back the surveys) so don't know if i would change my methods

anybody else have 2 cents to add?

Yes - you have a pain patient population that is 100% happy? Where do you practice, MARS?

 

[Aether2000]

We will continue to live in limbo regarding sedation until some definitive answers are available. The ASA position has typically been sedation is bad during pain procedures because some people were hurt during these procedures. We really don't know the risk due to variations in practice, types of sedation, and more importantly- the lack of any evidence based medicine to prove or disprove that sedation imposes any additional risks or unacceptable risks. The ASA practice guidelines are not based on evidence based medicine: they are opinions only, even if by "experts" that probably have not performed pain procedures with sedation. Therefore at this time, we have effectively no scientific data to argue one way or another on sedation. Because the relative risk of injury appears to be low, statistical evidence of sedation causing or alleviating problems during pain procedures would require very high numbers of patients, and I am not aware of any very large scale studies that have addressed these questions.

 

[Mister Mxyzptlk]

I find it hard to believe that 50-100 mcg of fentanyl and/or a couple mg of Versed would prevent a patient from yelling if you accidentally hit a nerve.

I am constantly perplexed when I hear about large populations of happy patients who had their procedures done without sedation. A significant number of my patients complain about the prep and an even larger number complain about the local. Sometimes I hear that sound of air being sucked between clenched teeth in my sleep.

Every once in a while I see a patient who has been to someone who never uses sedation. The op reports are glowing, but the patient's report is very much to the contrary. Sometimes I'll read the report back to them just to see the look of astonishment on their faces. Then I hear stories about horrible pain, tears, etc.

This leads me to conclude that the claims of consistent patient satisfaction while having painful body parts poked with needles without sedation are somewhat exaggerated. I certainly know it's possible to do some patients w/o sedation since I do a fair proportion of my cases under straight local, but it is the patient's choice, not something forced upon them.

Patient feedback is a funny business. There have been plenty of times that I have done a procedure that was definitely causing significant pain despite my best efforts, and afterward the patient thanked me and continued under my care. A lot of patients blame themselves for being a "baby" when perhaps the blame should be placed elsewhere. They might even apologize for their behavior.

Whatever the case, you should never make a patient feel bad for complaining during the procedure, even if you really did think they were overreacting. I always tell them that it's really hard to have these injections done and they did a great job.

 

[Tenesma]

of course those hospital surveys are bogus because only about 5-10% of people actually fill them out and send them back --- so i can proudly say that 100% of those 5% are happy --- i am sure that the real statistic like everything in pain is closer to placebo rates which is about 20-30%

i agree with gorback that it is the patient's choice... and i have a few patients who were with previous doctors who used sedation, and they insist that they need sedation with me as well.... I usually suggest that we try it without sedation and that we will be able to sedate them right away if there is a problem --- so far most of those changed their tune once they saw how quick the procedures really are... i am talking about bread and butter cases here

discal procedures, stimulators, etc are a TOTALLY different animal

what do you guys use? i know some ONLY do propofol... which i believe is moderate sedation --- but how much fentanyl/versed is moderate sedatioN?

 

[Mister Mxyzptlk]

I mix 2 ccs of fentanyl and 2 ccs of versed in a syringe. Keep pushing until they stop breathing, then 1 cc less.

Ok, seriously, that's what I do but without the apnea part if possible.

 

[Ligament]

I mix 2 ccs of fentanyl and 2 ccs of versed in a syringe. Keep pushing until they stop breathing, then 1 cc less.

Ok, seriously, that's what I do but without the apnea part if possible.

I like that Gorback.

I like propofol for the really painful procedures but as a physiatrist it is out of my expertise, even though it was used a hell of a lot in my fellowship (mixed with versed, fent, and ketamine).....😱

I like ketamine in very SMALL doses; the chronic pain population is sure as hell tolerant to your fent and versed but they aint never heard of no ketamine! With small doses I do not see any significant psychiatric issues.

 

[lobelsteve]

I like that Gorback.

I like propofol for the really painful procedures but as a physiatrist it is out of my expertise, even though it was used a hell of a lot in my fellowship (mixed with versed, fent, and ketamine).....😱

I like ketamine in very SMALL doses; the chronic pain population is sure as hell tolerant to your fent and versed but they aint never heard of no ketamine! With small doses I do not see any significant psychiatric issues.

I am afraid of a dreaded dissociative state type of reaction and the need to watch the patient for several hours should it occur.

 

[Ligament]

I am afraid of a dreaded dissociative state type of reaction and the need to watch the patient for several hours should it occur.

I've never seen that myself with very small doses and have asked a lot of my general anesthesiology professors about this issue. It seems to break down to this; those that use Ketamine in "induction doses" have seen this dissociative reaction with emergence problems, FREQUENTLY. Many of the anesthesiologists I talked to have rarely or never used it in very small doses. The ones that have, have absolutely no problems with it and actually encouraged me to use it as a SAFE medication.

As you all know, I'm a physiatrist so it was enlightening to me to see the dichotomy between the levels of ketamine usage patterns with anesthesiologists.

I've brought this topic up from time to time on this forum and usually had mixed responses, which I'm fine with. I'm not arguing the point. I'm not trying to be an outlier with sedation nor do anything dangerous. On the contrary, this medication has just about the most ideal safety profile possible. It has no reversal agent, but the need for one is so low...

Also, consider Fent and Versed. About 90% of the chronic pain population are tolerant to both classes of these medications. Who is tolerant to Ketamine? Only people I can think of are the NYC club kids from the 90's who spent every weekend in a "K-hole," and even then I don't know whether tolerance develops.

Best regards.

 

[Mister Mxyzptlk]

This is an interesting idea that has never occurred to me. Back in a previous incarnation doing hyperbaric medicine we did a lot of whirlpool wound treatments using ketamine analgesia and it worked really well. I agree that they don't get the dysphoric or hallucinogenic side effects at low doses, yet I am still leery about using it in the office.

What doses are you using and about how many procedures have you done this way?

 

[Doctodd]

If i remember correctly, if you are doing this "conscious sedation" in the office, you may not be doing a level 1 surgery any more cuz the patient is not "responsive"....and that is the gray area. If you are doing more than a level 1 surgery, you need to jump thru many more hoops. I used quotes on purpose.

T

 

[Ligament]

If i remember correctly, if you are doing this "conscious sedation" in the office, you may not be doing a level 1 surgery any more cuz the patient is not "responsive"....and that is the gray area. If you are doing more than a level 1 surgery, you need to jump thru many more hoops. I used quotes on purpose.

T

The ASA defines "moderate sedation/conscious sedation" as being able to provide "purposeful response to verbal or tactile stimulation". So if they are not "responsive", it is deep sedation (or general!) and now you are not doing "moderate sedation" and cannot bill for 99144.

http://www.asahq.org/publicationsAnd...dation1017.pdf

More info on billing for 99144 in "CPT for fluoroscopy" thread.
http://forums.studentdoctor.net/showthread.php?t=472953

 

[paintyper]

I am a chronic pain patient (a big baby when I hurt with a huge needle phobia), and I do not understand why patients have to be sedated for epidurals or other injections. I have always gotten them in the office with no sedation. I also have been transcribing pain management reports for years. Why do these patients need to be sedated for the injections? On my first stimulator implant (hello, no sedation or anything), the doctors were running the wires up and down my back (buttocks to head) for hours tunneling those wires (I have no fat back there). I do not understand why the sedation.

 

[paintyper]

It does not matter how much the injections hurt, as long as we get pain relief in the end. 🙂 I am truly the biggest baby there is, and I have always gotten my epidurals, occipital nerve blocks, supraorbital nerve blocks, TPIs, etc., and even a 6-hour stimulator implant (with nothing for pain) with doctors running those wires from my buttocks to my head and through my back over and over for hours on end (I have no fat back there). All we think are "Yummy, pain relief! Yummy steroids! Yummy Botox! I am going to feel so much better." I wish you could see your patients leave after those injections, especially steroids. I watch them come out of my doctor's office. They all have big wide grins like they just had "the best night of their life." Thank you to all pain management doctors for making us or keeping us functional. 😀Pain management doctors are the true Gods! Thank you all very much! Thank you mankind and pain doctors for steroids, Botox, RF, cryo, stimulators, etc. Keep up the excellent work. 😍

 

[paintyper]

I have been receiving ESIs as well as other injections for over 7 years, and I have never needed or wanted to be sedated for these. It is either just a pinch or a pressure feeling that lasts a few seconds. Even when the doc hits a nerve, it is a brief "lightening bolt." It is a lot easier than going to the dentist, and you usually do not have to look at the big needle. All we (chronic pain patients) care about is the pain relief afterwards, not how much it hurt to get it. You should see the huge smile we are wearing when we leave. Supraorbital nerve blocks hurt more than ESIs by far---Lovin' steroids and Botox...A Patient's Point of View...

 

[Doctodd]

i see no harm in a little cheering section...of course that is all it should be considered as unless he starts PMing docs for office appointments.....then i would feel like a hollywood star with a stalker. Paintyper.....glad you feel better. But 6 hours for an implant?

T

 

[Mister Mxyzptlk]

I do not understand why the sedation.

I'm just guessing here: Because everyone isn't like you?

[kill-filed]

 

[Tenesma]

so over the last month I have been offering sedation to all those patients who have received injections from me in the past --- out of 120 patients so far, not ONE of them requested sedation for their upcoming procedure - and I have been trying to sell it hard... even some of the super anxious patients that i thought i would win over to sedation were resistant, but one did ask for a pre-procedure xanax ...

so i agree with paintyper - it is all about the soothing voice and the RN holding the patients hand and minimal needle re-positioning with good local anesthesia.

 

[Mister Mxyzptlk]

Like Todd Rundgren, "a wizard, a true star".

 

[Tenesma]

dude i am only talking about straight-forward ESIs, TFESIs, Facets, SI, Joints - if i could generate more profit by doing procedural sedation i would be happy, but there doesn't appear to be much of a need for it.

in fact, i had a lady today that i did SI joints - and she jumped in the air from just the local - so after the procedure, i asked her if she wanted sedation the next time - and again, i got shot down

maybe it is just my geographical area?

 

[Mister Mxyzptlk]

maybe it is just my geographical area?

Could be. Exactly how do I find Never Never Land? It's not in my atlas.

 

[ampaphb]

so over the last month I have been offering sedation to all those patients who have received injections from me in the past --- out of 120 patients so far, not ONE of them requested sedation for their upcoming procedure - and I have been trying to sell it hard... even some of the super anxious patients that i thought i would win over to sedation were resistant, but one did ask for a pre-procedure xanax ...

so i agree with paintyper - it is all about the soothing voice and the RN holding the patients hand and minimal needle re-positioning with good local anesthesia.

We use Versed on everyone (2-5mg), and local only on interlaminars, caudals, and discos. We find the local is more painful than the injection when using a 25g spinal needle on TFEs, facets, and SIs.

Also, if the patient''s pain relates, in part, to muscle spasm, it has been my anecdotal experience that the Versed has a therapeutic effect as well.

 

[lobelsteve]

We use Versed on everyone (2-5mg), and local only on interlaminars, caudals, and discos. We find the local is more painful than the injection when using a 25g spinal needle on TFEs, facets, and SIs.

Also, if the patient''s pain relates, in part, to muscle spasm, it has been my anecdotal experience that the versed has a therapeutic effect as well.

When you use Versed, is it 1 for you, 1 for me, or does the patient get all of it?

 

[Tenesma]

versed 2-5mg for everybody --- wow --- you are within a few mg of doing a colonoscopy ...

which is amazing because when i did anesthesia we were able to MAC for AV grafts in the forearm with 1mg of Versed and 50-75mcg of Fentanyl and some local...

it is really interesting to see the regional variations on sedation

now does 2-5mg of versed count as "moderate sedation" for billing purposes?

 

[Doctodd]

steve...you are confusing versed with fentanyl. That is the drug of choice. Did you ever have any attendings who "really liked" fentanyl?

T