Sedation for colonoscopy: an international perspective

The variation in sedation practices worldwide reflects the diversity of social, cultural, medicolegal, economic, and market factors that influence patient tolerance for colonoscopy as well as the willingness and ability of endoscopists to expend the time, effort, and resources required for the safe and effective use of sedation. In the United States, the use of endoscopic sedation has been standard practice during endoscopy since the introduction of fiber-optic gastroscopy in the early 1950s. Today, more than 98% of all colonoscopies in the United States are performed with either moderate sedation or monitored anesthesia care (MAC).

In Europe, sedation practices have evolved during the past decade. For example, a study in 1999 indicated that most colonoscopies in Germany were performed without intravenous sedation. Less than 10 years later, a publication by the German Society for Digestive and Metabolic Diseases indicated that the use of intravenous sedation during colonoscopy in that country was nearly 88%. A similar trend has been observed in Switzerland, where the use of sedation during colonoscopy increased from 60% to 78% between 1990 and 2003. During this time, the average number of colonoscopies performed annually by a Swiss endoscopist increased nearly 60%. Most of these colonoscopies were performed using a benzodiazepine and an opioid, although 34% of endoscopists indicated that they routinely administered propofol. The use of propofol by endoscopists in Germany is also growing, according to anecdotal reports.

Sedation practices vary considerably throughout Europe, however. In 2007, a survey of 278 centers throughout Italy reported that sedation was used during 55% of colonoscopies. The methods of sedation included benzodiazepine alone (28%), benzodiazepine and opioid (15%), propofol (3%), and other method of sedation (8%). In 2008, a survey of 197 endoscopy centers in Spain indicated that most used sedation for at least 50% of their colonoscopies. The agents used included benzodiazepine alone (13%), benzodiazepine and opioid (39%), opioid alone (15%), propofol (21%), and unspecified (12%). A nationwide survey of Greek endoscopists in 2007 found that 78% of respondents used intravenous sedation routinely during colonoscopy. Unsedated colonoscopy is increasingly uncommon in Europe, according to a recent survey that found it to be the dominant method of sedation in only 5 European countries: Norway, Poland, Russia, Serbia, and Montenegro.

The data available regarding sedation practices in Asia and Africa are sparse. Anecdotal information based on surveys of small numbers of individuals practicing within these 2 continents indicates that the use of sedation varies considerably from country to country. For example, the use of sedation during colonoscopy in Asia ranged between 0% and 100% of cases, with the highest use rates in Australia and Hong Kong (100%), and the lowest rates in China and Taiwan (0%–15%). A similar situation exists in Africa, where sedation use is closely linked to the economic environment of the individual practice and the country. Among 13 African endoscopy units that were surveyed, 100% responded that sedation was administered during most colonoscopies. In most instances, midazolam was used alone, although almost half of those surveyed indicated that propofol was used in some cases. Benson and colleagues reported similar findings regarding sedation practices in Africa and Asia, based on a survey of 165 endoscopists practicing worldwide.

In summary, the administration of sedation during colonoscopy has evolved during the past decade. Today, relatively few countries exist where most examinations are performed without sedation. In spite of cultural, social, and medicolegal differences that exist from one region to another, market demand and economic considerations are the dominant forces influencing the practice of sedation during colonoscopy.

The economic implications of sedation

Historically, sedation has been the responsibility of the endoscopist, assisted by a nurse or endoscopy technician. The administration of moderate sedation involves a variety of tasks including the pre-procedure evaluation, establishment of intravenous access and delivery of fluids, administration of intravenous medications, patient monitoring both during and after the procedure, recovery assessment, and patient discharge. Additional sedation-related functions include documentation, maintenance of emergency equipment, and medication inventory. It has been estimated that this work, combined with the practice expense of sedation, account for up to 40% of the total overhead cost of an endoscopic examination. With estimates of the direct overhead cost of colonoscopy ranging from $200 to $400, the approximate cost of providing moderate sedation works out to $80 to $160 per procedure.

Reimbursement for the cost of sedation is bundled into the professional fee for endoscopy, according to Appendix G of the American Medical Association’s Current Procedural Terminology (CPT). Consequently, when an endoscopist performs sedation during an endoscopic procedure, a separate charge for this service is not permitted under Centers for Medicare and Medicaid Services (CMS) policy. Many commercial payers, following the lead of CMS, have also adopted this policy.

The value that CMS has placed on sedation services cannot be accurately determined, as the endoscopic CPT codes include no relative value units for the physician work that is directly attributed to sedation administration. New CPT codes for moderate sedation (99143-99145) were established in 2006 for instances in which the provider of sedation also performed the diagnostic or therapeutic procedure. However, CMS policy precludes the use of these codes for procedures listed in Appendix G, which encompasses all of the endoscopic procedures. Moreover, CMS deems these codes to be carrier priced, and has not established relative value units for these services.

The exclusion of sedation as a unique service for procedures listed within Appendix G does not apply to anesthesia services. Complex procedures and procedures in high-risk patients are considered circumstances in which the presence of an anesthesia specialist is considered necessary and appropriate. A statement issued jointly by the American Gastroenterological Association (AGA), the American College of Gastroenterology (ACG), and the American Society for Gastrointestinal Endoscopy (ASGE) supports this conclusion, indicating that the routine use of an anesthesiologist for average-risk patients undergoing standard upper and lower endoscopic procedures is not warranted ( Box 1 ). That notwithstanding, the use of anesthesia services in the United States has grown considerably during the past decade. Estimates suggest that an anesthesia provider is involved in 30% or more of all endoscopic procedures, and this number is projected to grow by 20% or so annually during the next several years. Similar changes have been observed in some provinces of Canada. For example, the proportion of colonoscopies in Ontario involving an anesthesiologist increased from 8% to 19% between 1993 and 2005. The economic impact of this trend is considerable. If sedation were to be provided by an anesthesiologist for all colonoscopies performed in the United States, which now exceed 15 million annually, the cost for this service would exceed $7.2 billion a year! This figure is based on an average reimbursement rate of $480 per case for anesthesia services. The potential economic and clinical consequences of this additional expense on the practice of gastroenterology, and colonoscopy in particular, have been reviewed in detail in several recent articles.

Traditionally, anesthesiologists performing ambulatory anesthesia for endoscopy have billed independently for their services. In some areas of the country, it is routine for the anesthesiologist to be nonparticipating in health insurance plans even though the endoscopist and the facility may be in-network. Under such an arrangement, it would not be unusual for the endoscopist to be paid $500 to $600 for performing a colonoscopy, whereas the anesthesiologist is reimbursed as much as $1000 or more. A recent review of this subject indicated that the commercial anesthesia fee for lower endoscopy (CPT code 00810) is 60% higher than the endoscopist’s fee (CPT code 45378), based on the relative value units for each code.

This disparity in compensation has prompted some endoscopists and facility owners to develop alternative business models to capture some of the revenue generated by anesthesia services. One approach that has been used is renting or leasing space, equipment, and/or personnel to the anesthesia group, or by charging for billing and collection services. Provided that the charges are set at fair market value, such an arrangement would qualify for safe harbor protection and would not be construed as a kickback. If the group is charged above-market rates, however, it is very possible that the excess payment would be characterized as a kickback, which was provided in exchange for the right to provide anesthesia services.

Recently, some ambulatory endoscopy centers have shifted to an “in-house model,” which involves contracting with or hiring an anesthesia provider. In this model, the anesthesia provider becomes an employee of the facility or practice and is paid a salary for his or her services. The facility then bills and retains the professional fees for the anesthesia services. Under such an arrangement, some payers may decline to reimburse a facility fee as well as payment for the anesthesia professional services under a single tax identification number.

An alternative to the in-house model is the “company model,” whereby either the physician practice or facility forms a new company (an anesthesia services company) for the explicit purpose of employing anesthesia providers, either anesthesiologists or certified registered nurse anesthetists. The anesthesia services company bills for the anesthesia services and pays a salary to the providers, and the profits from this company are shared by the company’s owners. Some estimates place the distributed profits at 40% or more of the anesthesia fees. Because the owners of the anesthesia company do not have to be the same individuals who own the practice or facility, this model provides an opportunity to select only those individuals who should be involved in this ancillary business activity, rather than dividing the profits among all owners of the facility or practice. From a regulatory perspective, the status of the company model remains uncertain, as the arrangement could be viewed as a contractual joint arrangement under the federal antikickback statute. The American Society of Anesthesiology (ASA) has requested the Office of Inspector General to issue a Special Advisory Bulletin clarifying the legality of the company model, but the status of this request remains uncertain at the time of writing.

What conclusions can be drawn from the preceding analysis? First, reimbursement for sedation administered by an endoscopist is insufficient to cover the cost of providing this service. Although most endoscopists in the United States continue to administer sedation, this imbalance between cost and reimbursement remains a powerful motivation for an ever-growing number of endoscopists to involve an anesthesia provider. Second, anesthesiologist-assisted endoscopy offers several benefits to the endoscopist, including the remarkable drug propofol, the services of an additional medical provider, and, in some instances, added revenue for the practice or facility. Third, the presence of a second provider for sedation adds considerably to the cost of colonoscopy with little or no improvement in the quality or safety. In a recent editorial in Anesthesiology , Orkin and Duncan referred to this practice as an example “in which low-benefit services and procedures result in disproportionate expenditures… [and] … are ideal substrate for health care reform.” To address these issues, we must reexamine and modify the current system of coding and reimbursement for procedural sedation. Changes to be considered include (1) a revision of payment levels for procedural sedation to better align compensation with the work and practice expenses associated with this service, (2) a reduction in professional fees for proceduralists who delegate sedation to a second provider, and (3) the development of guidelines that define those procedures and patients in whom the involvement of an anesthesiologist is medically appropriate.

The economic implications of sedation

Historically, sedation has been the responsibility of the endoscopist, assisted by a nurse or endoscopy technician. The administration of moderate sedation involves a variety of tasks including the pre-procedure evaluation, establishment of intravenous access and delivery of fluids, administration of intravenous medications, patient monitoring both during and after the procedure, recovery assessment, and patient discharge. Additional sedation-related functions include documentation, maintenance of emergency equipment, and medication inventory. It has been estimated that this work, combined with the practice expense of sedation, account for up to 40% of the total overhead cost of an endoscopic examination. With estimates of the direct overhead cost of colonoscopy ranging from $200 to $400, the approximate cost of providing moderate sedation works out to $80 to $160 per procedure.

Reimbursement for the cost of sedation is bundled into the professional fee for endoscopy, according to Appendix G of the American Medical Association’s Current Procedural Terminology (CPT). Consequently, when an endoscopist performs sedation during an endoscopic procedure, a separate charge for this service is not permitted under Centers for Medicare and Medicaid Services (CMS) policy. Many commercial payers, following the lead of CMS, have also adopted this policy.

The value that CMS has placed on sedation services cannot be accurately determined, as the endoscopic CPT codes include no relative value units for the physician work that is directly attributed to sedation administration. New CPT codes for moderate sedation (99143-99145) were established in 2006 for instances in which the provider of sedation also performed the diagnostic or therapeutic procedure. However, CMS policy precludes the use of these codes for procedures listed in Appendix G, which encompasses all of the endoscopic procedures. Moreover, CMS deems these codes to be carrier priced, and has not established relative value units for these services.

The exclusion of sedation as a unique service for procedures listed within Appendix G does not apply to anesthesia services. Complex procedures and procedures in high-risk patients are considered circumstances in which the presence of an anesthesia specialist is considered necessary and appropriate. A statement issued jointly by the American Gastroenterological Association (AGA), the American College of Gastroenterology (ACG), and the American Society for Gastrointestinal Endoscopy (ASGE) supports this conclusion, indicating that the routine use of an anesthesiologist for average-risk patients undergoing standard upper and lower endoscopic procedures is not warranted ( Box 1 ). That notwithstanding, the use of anesthesia services in the United States has grown considerably during the past decade. Estimates suggest that an anesthesia provider is involved in 30% or more of all endoscopic procedures, and this number is projected to grow by 20% or so annually during the next several years. Similar changes have been observed in some provinces of Canada. For example, the proportion of colonoscopies in Ontario involving an anesthesiologist increased from 8% to 19% between 1993 and 2005. The economic impact of this trend is considerable. If sedation were to be provided by an anesthesiologist for all colonoscopies performed in the United States, which now exceed 15 million annually, the cost for this service would exceed $7.2 billion a year! This figure is based on an average reimbursement rate of $480 per case for anesthesia services. The potential economic and clinical consequences of this additional expense on the practice of gastroenterology, and colonoscopy in particular, have been reviewed in detail in several recent articles.

Box 1

• •
  

  In general, diagnostic and uncomplicated therapeutic endoscopy and colonoscopy are successfully performed with moderate (conscious) sedation.

  
  
• •
  

  Compared with standard doses of benzodiazepines and narcotics, propofol provides 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 sedation have not been consistently demonstrated in average-risk patients undergoing routine upper and lower endoscopy. Further randomized clinical trials are needed in this setting.

  
  
• •
  

  Propofol may have clinically significant advantages when used for prolonged and therapeutic procedures, including, but not limited to, endoscopic retrograde cholangiopancreatography and endoscopic ultrasound.

  
  
• •
  

  There are data to support the use of propofol by adequately trained nonanesthesiologists. 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 patients 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 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 sedation.

  
  
• •
  

  Billing separately for conscious sedation has been targeted by the Office of Inspector General as a possible fraud and abuse violation, and is not recommended.

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