Is there a way to be reimbursed for nitrous oxide administration?

I’m starting to use nitrous oxide in my practice for office procedures. I keep hearing there is no billable code for nitrous and that you have to charge the patient cash. One practice I talked to said they found a way to bill the disposables like the face mask and the tubing as a way not to bill the patient. Is that possible? I am just trying to do my due diligence to be able to operationalize this in the office.

Jonathan Rubenstein, MD

Nitrous oxide has been used for more than 150 years in medical settings, most notably in dental services. There has recently been an increased interest in the use of nitrous for nondental surgical procedures, which may increase patient comfort and potentially reduce the need for general anesthesia in some cases. Administered through inhalation, commonly via nasal tubing, nitrous oxide is expelled through respiration, with an elimination half-life of approximately 5 minutes. Nitrous may be administered under continuous regulated flow or self-administered by the patient, with the latter felt to be a safety feedback loop as patients need to be awake enough to administer additional doses of nitrous. A few thoughts about using nitrous for (nondental) surgical procedures:

Mark Painter

1. According to guidelines published by the American Society of Anesthesiologists (ASA), nitrous oxide that is not administered in a manner that is continuous or intermittent is considered to be minimal sedation or analgesic:

“Examples of minimal sedation include peripheral nerve blocks, local or topical anesthesia, and either (1) less than 50% nitrous oxide (N2O) in oxygen with no other sedative or analgesic medications by any route, or (2) a single, oral sedative or analgesic medication administered in doses appropriate for the unsupervised treatment of insomnia, anxiety, or pain.”

2. Nitrous oxide is not site specific. It is not considered to be either a topical or local anesthetic, services that are considered bundled into the global of surgical services. Nitrous oxide is not directed to a specific nerve and is therefore not considered a nerve block, which is covered under most health care plans under specific coverage criteria.

2. The vast majority of insurance programs, including Medicare, consider analgesia or minimal sedation not classified as regional or local anesthetic as a service provided for patient comfort. By definition, services and supplies provided for patient comfort are considered noncovered or not paid for by Medicare. Noncovered services and supplies can be provided to a patient but are the liability of the patient and do not require an advanced beneficiary notice (ABN). These charges are not regulated by Medicare fee schedules. The majority of private payers follow Medicare policies with regard to noncovered services; however, we would encourage any practice providing a noncovered service to check payer contracts for specific rules related to noncovered services.

Based on the definitions from the ASA and coverage rules for Medicare, the use of nitrous oxide for urology procedures is a noncovered service. As a noncovered service, a practice considering offering nitrous oxide to patients undergoing a procedure is able to provide the service without an ABN with the patient responsible for payment when it is chosen. As with any service offered for which the patient is required to pay, the practice will need to explain the price, options, risks, and benefits of the service and have the patient agree to pay. Most private payers will follow Medicare rules in this regard.

There are currently no identifiable Current Procedural Terminology (CPT) codes available for reporting this service without continuous flow supervised nitrous administration. Additionally, the typical global surgical packaging does not allow anesthesia to be reported if provided by the same provider as the surgical procedure. Consequently, as noted above, billing this use of nitrous oxide to an insurer is not generally feasible. However, contractual agreements with private payers allow for discussion and perhaps carve-outs or alternative reimbursement for supplies as you have mentioned. In short, if you want to provide these services and be reimbursed by the insurance company, you will need to negotiate.

Lastly, we would like to add a consideration for financial outcomes. The advantage to noncoverage for services under insurance contracts is that noncovered services are not price controlled. In 2021, out-of-pocket expenditures for health care grew 10.4% and now represent 10% of the total National Health Expenditures, according to the Centers for Medicare & Medicaid Services National Health Expenditure Fact Sheet. Noncovered services also represent a separate revenue stream for offices in an environment where reimbursement from health insurance companies, largely benchmarked to Medicare, have decreased or remained flat for the past 10 years. In short, collection of deductibles, co-payments, and co-insurance from patients is a must in today’s health care marketplace. With patients now being asked to pay for routine health care services, it is now common for urology groups to offer additional services to be paid by the patient. So be careful what you ask for, you just might get it.

Send coding and reimbursement questions to Jonathan Rubenstein, MD, and Mark Painter c/o Urology Times®, at UTeditors@mjhlifesciences.com.

Questions of general interest will be chosen for publication. The information in this column is designed to be authoritative, and every effort has been made to ensure its accuracy at the time it was written. However, readers are encouraged to check with their individual carrier or private payers for updates and to confirm that this information conforms to their specific rules.