The administration of conscious sedation for endoscopic procedures, by the same provider, regardless of specialty, is not eligible for separate payment. Reimbursement for conscious sedation is included in the global allowance for diagnostic and uncomplicated therapeutic endoscopic procedures and, therefore, is not separately reimbursable. A participating, preferred, or network provider cannot bill the member for the conscious sedation. (The procedure codes representing these services are listed in the Procedure Code Attachment below.)

Conscious sedation performed with any other surgical procedure by the same provider remains not covered.  A participating, preferred, or network provider can bill the member for the conscious sedation (see Highmark Medical Policy Bulletin A-2 for these guidelines).

Conscious sedation performed by other than the operating surgeon, assistant surgeon, or attending professional for a covered surgical service remains eligible for separate payment.

Description

Conscious sedation induces an altered state of consciousness that minimizes pain and discomfort through the use of pain relievers and sedatives. Patients who receive conscious sedation usually are able to speak and respond throughout the procedure.

Under the HMO (only), anesthesia performed by the operating physician, his assistant, or the attending provider is eligible for separate payment when performed in conjunction with covered services which have been authorized by the PCP or designated specialist and the Plan.

PRN References

10/2004, Conscious sedation administered for endoscopic procedures, by same provider not paid separately