Aetna has decided for their members that the services of an anesthesiologist or CRNA in the office-based setting is not medically necessary for healthy patients undergoing routine endoscopic procedures.
Their mindset in the hospital setting is not altogether different and has implications beyond just patient care. Aetna is no longer acknowledging the ASA RVG CPT codes (00740 and 00810) used by anesthesiologists and CRNAs when anesthesia care is provided to endoscopy patients in the hospital and ASC settings. Rather, Aetna will be allowing codes reimbursing anesthesiologists and CRNAs as though the endoscopists were themselves contemporaneously providing anesthesia and endoscopy services (99149 and 99150). It remains unclear if reimbursement will track toward the 00740/00810 or the 99149/99150 codes. These terms and conditions, again, are independent of the anesthesia medications used and the relevant limitations placed by state regulatory and nursing boards.
The American Society of Anesthesiologists and the American Society for Gastrointestinal Endoscopy were consulted prior to this policy change, which was made by Aetna after reviewing a document published on March 8, 2004 by the American College of Gastroenterology, American Gastroenterological Association and the American Society for Gastrointestinal Endoscopy.1 The scientific underpinnings of their assertion that patient safety is unencumbered when an alternate provider, rather than an anesthesiologist or CRNA, is used during the administration of propofol have not been endorsed by the ASA. Furthermore, studies across various patient populations and sites of services have not been completed. Moreover, the role of anesthesia type and provider on helping or hindering polyp detection outcomes has not been thoroughly studiedóbut the tenets of multitasking do suggest that an effect may be seen if both tasks are carried out by the same physician.
The recent refrain, also creates a potentially dangerous back peddle on patient safety and creates a situation where dual standards of care may flourish. For instance, patients undergoing endoscopy in a hospital or ASC setting are subject to different policies compared to patients cared for in an office setting. Similarly, a patient who is 17 or 66 years old will be covered if they are cared for by an anesthesiologist or CRNA whereas a patient who is 18 or 65 years old will not. In a policy soon to be released by Anthem, the concept of a dual standard of care is perpetuated and this seems to be a unifying mantra among payers in general.
According to its website, some Aetna members have access to special programs, including discounts on visits to acupuncturists, chiropractors and massage therapists and health club memberships.2 Anthem offers similar discount programs.3 In front of this backdrop, it is regrettable that the financial commitment to fully and appropriately compensate an anesthesiologist or a CRNA for anesthesia care provided during the conduct of an endoscopy for cancer screening purposes has come under fire.
We urge you to write your local Congressman and Senators, patients, and provider representatives as well as to marshal the support of your GI colleaguesómost of whom do not necessarily support the current or anticipated decisions. Please go the www.safepropofol.org website for a sample letter to Aetna. ASAPís position is that the ACG, ASA nor corporations such as Aetna should be weighing in on medical necessity including defining which patients should and should not be receiving anesthesia. This decision should be made by the doctor performing the endoscopy, the anesthesia provider and the patientówithout financial penalty, rather than a well removed third party.
Moreover, remind them that reimbursing anesthesia as a nominal flat fee (99149/99150) based upon the level of anesthesia and sedation is a profoundly dangerous step onto a very slippery slope. That is, one where anesthesia for cataract surgery, wrist surgery or knee arthroscopy performed under local anesthesia with sedation will potentially be the next targets in the cross hairs. Paying anesthesiologists and CRNA as though they were a surgical provider and/or happenstance assistant providing a dollop of medication prior to surgery devalues our role in patient care and minimizes our longstanding role in patient safety. Adverse events can occur with healthy patients, during minor or brief procedures under nominal anesthetics.
Specifically, let them know that individual Anesthesiologists, CRNA and GI physicians should collectively be choosing the type of anesthesia their patients receive as well as the professional administering it-- and they should be allowed to do so without penalty. These decisions should be made on a patient by patient basis not through edicts from large corporations or professional societies.
We do not stand alone in our concern, former past president of the ACG, Dr. John Popp recently sent a letter to Wellpoint, Inc touching upon many of the aforementioned issues. This letter can be found at www.safepropofol.org/wellpoint.pdf.
Marc E. Koch, MD
Anesthesiologist for the Safe Administration of Propofol [ASAP]