2010-04-12 19:14:40 UTC

Gastroenterology Societies Reach Consensus on Recommendations for Sedation During Endoscopic Procedures

The joint statement clarifies billing issues related to the administration and/or supervision of sedation/anesthesia, summarizes current data on sedative agents and makes recommendations regarding the appropriate use of anesthesia specialists for endoscopy and appropriate patient surveillance during sedation.

The American College of Gastroenterology, American Gastroenterological Association and American Society for Gastrointestinal Endoscopy today issued a jointly sponsored statement on sedation for endoscopy. The joint statement clarifies billing issues related to the administration and/or supervision of sedation/anesthesia, summarizes current data on sedative agents and makes recommendations regarding the appropriate use of anesthesia specialists for endoscopy and appropriate patient surveillance during sedation.

The statement, approved by the governing boards of the three societies, is the product of a six member committee composed of representatives from each of the three societies. The impetus for the work of the committee was confusion regarding billing issues and recent developments and trends in sedation practice, including the use of propofol.

The group made several recommendations with important implications for endoscopic practice:

  • The joint society recommendations assert that: “Compared to standard doses of benzodiazepines and narcotics, propofol may provide faster onset and deeper sedation…More rapid cognitive and functional recovery can be expected with the use of propofol as a single agent.”
  • The joint society recommendations indicate that there are data to support the use of propofol by adequately trained non-anesthesiolgists: “Large case series indicate that with adequate training, physician-supervised nurse administration of propofol can be done safely and effectively.”
  • The joint society recommendations note that: “Reimbursement for conscious sedation is included within the codes covering endoscopic procedures.”

The recommendations review key issues regarding proper billing protocols, patient safety, the management of complications and the importance of training and skills necessary to rescue patients from severe respiratory depression.

Full text of the statement follows and it may be modified as future developments occur.

RECOMMENDATIONS ON THE ADMINISTRATION OF SEDATION
FOR THE PERFORMANCE OF ENDOSCOPIC PROCEDURES

A Joint Statement of a Working Group from the American College of Gastroenterology (ACG), the American Gastroenterological Association (AGA) and the American Society for Gastrointestinal Endoscopy (ASGE)

  • In general, diagnostic and uncomplicated therapeutic endoscopy and colonoscopy are successfully performed with moderate (conscious) sedation.
  • Compared to standard doses of benzodiazepines and narcotics, propofol may provide faster onset and deeper sedation.
  • More rapid cognitive and functional recovery can be expected with the use of propofol as a single agent.
  • Clinically important benefits over standard sedatives have not been consistently demonstrated in average-risk patients undergoing standard routine upper and lower endoscopy. Further randomized clinical trials are needed in this setting.
  • Propofol may have more clinically significant advantages when used for prolonged and therapeutic procedures, including, but not limited to, ERCP and EUS.
  • There are data to support the use of propofol by adequately trained non-anesthesiologists. Large case series indicate that with adequate training physician-supervised nurse administration of propofol can be done safely and effectively. The regulations governing the administration of propofol by nursing personnel vary from state to state.
  • Patients receiving propofol should receive care consistent with deep sedation. Personnel should be capable of rescuing the patient from general anesthesia and/or severe respiratory depression.
  • A designated individual, other than the endoscopist, should be present to monitor the patient throughout the procedure and should be able to recognize and assist in the management of complications.
  • The routine assistance of an anesthesiologist/anesthetist for average risk patients undergoing standard upper and lower endoscopic procedures is not warranted.
  • Physician-nurse teams administering propofol should possess the training and skills necessary to rescue patients from severe respiratory depression.
  • Complex procedures and procedures in high-risk patients may justify the use of an anesthesiologist/anesthetist to provide conscious and/or deep sedation. In such cases this provider may bill separately for their professional services.
  • The use of agents to achieve sedation for endoscopy must conform to the policies of the individual institution.
  • Reimbursement for conscious sedation is included within the codes covering endoscopic procedures.
  • Billing separately for conscious sedation has been targeted by the OIG as a possible fraud and abuse violation, and is not recommended.

The members of the working group were: Damian Augustyn, M.D. (San Francisco, CA), Joel V. Brill, M.D. (Scottsdale, AZ), Douglas Faigel, M.D. (Portland, OR), Bergein F. Overholt, M.D. (Knoxville, TN), John W. Popp, Jr., M.D. (Columbia, SC), Maurits Wiersema, M.D. (Fort Wayne, IN).