LCD/NCD Portal

L30561

 

MONITORED ANESTHESIA CARE (MAC) FOR CERTAIN INTERVENTIONAL

PAIN MANAGEMENT SERVICES

 

 

01/01/2013

 

 

Indications and Limitations of Coverage and/or Medical Necessity

• Monitored anesthesia care (MAC) is a specific anesthetic service for a diagnostic or therapeutic procedure.

• This LCD specifically addresses the use of MAC with certain interventional pain management procedures (CPT codes 20550, 20551, 20552, 20553, 27096, 62310, 62311, 64479, 64480, 64483, 64484, 64490, 64491, 64492, 64493, 64494 and 64495) where current practice supports that local anesthesia alone, inclusive of these procedures, is typical.

o For certain patients, the addition of mild sedation (physician service not separately payable) or moderate (conscious) sedation (CPT codes 99143-99150), may be part of these minimally invasive procedures.

o As outlined in this LCD, the addition of MAC, a second physician service (or other qualified anesthesia provider service), to the episode of care for these services must meet, but not exceed, the patient’s medical need and be furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient’s condition.

• MAC results in two physician services and is not usually medically necessary for interventional pain management procedures addressed in this LCD. MAC may be considered medically necessary, based on the nature of the procedure, the patient’s clinical condition and/or the potential need to convert the patient from MAC to a general or regional anesthetic. MAC includes all aspects of general anesthesia care (pre-procedure through post-procedure), which includes:

o Pre-procedure/pre-anesthetic visit/exam (includes but is not limited to the patients medical history, information related to present illness, social history, allergies, review of systems as applicable and a physical examination)

o Prescription of the anesthesia care required

o Administration of any necessary oral or parental medications (e.g., atropine, Demerol, valium)

o Post-operative anesthesia care

• During MAC, the anesthesiologist or qualified anesthesia provider renders a number of specific services including but not limited to the following:

o Support of vital functions. Monitoring of vital signs, maintenance of the patient’s airway and continual evaluation of vital functions in the anticipation of the need for the administration of general anesthesia or of the development of adverse physiological patient reaction to the procedure.

o Diagnosis and treatment of clinical problems that occur during the procedure.

o Administration of sedatives, analgesics, hypnotics, anesthetic agents or other medications as necessary for patient safety.

o Psychological support and physical comfort.

o Provision of other medical services as needed to complete the procedure safely.

• Medicare pays for reasonable and necessary MAC services on the same basis as other anesthesia services. Anesthesiologists use modifier QS to report monitored anesthesia care cases.

o Monitored anesthesia care involves the intraoperative monitoring by a physician or qualified individual under the medical direction of a physician or of the patient’s vital physiological signs in anticipation of the need for administration of general anesthesia or of the development of adverse physiological patient reaction to the surgical procedure.

• Monitored anesthesia care often includes the administration of doses of medications for which the loss of normal protective reflexes or loss of consciousness is likely.

o If the patient is rendered unconscious and/or loses normal protective reflexes, the anesthesia care is considered a general anesthetic.

 

 

Indications

• Monitored anesthesia care will be considered medically reasonable and necessary when the patient’s condition requires the presence of a second physician represented by an anesthesiologist or qualified anesthesia provider in addition to the provider performing the procedure.

o The patient’s medical condition or nature of the procedure must require the presence of a second physician represented by an anesthesiologist or qualified anesthesia provider to administer the sedation if utilized, to manage the airway & vital signs, and to continually assess the patient for clinical problems and treat appropriately to ensure patient safety and comfort.

o The presence of an underlying condition alone or a stable treatable condition is not sufficient evidence that monitored anesthesia care is medically reasonable and necessary.

• Monitored anesthesia care for interventional pain management services will be considered medically reasonable and necessary when the following criteria are met:

o Co-morbidities that would require the services of an anesthesiologist or qualified anesthesia provider such as pulmonary disease, cardiac disease, and/or psychiatric conditions with accompanying active symptoms necessitating close monitoring during the procedure, morbid obesity, severe sleep apnea, inability to follow simple commands (i.e., cognitive dysfunction with the inability to perform ADLs and provide self-care, dementia or developmental delay), spasticity disorders that would make it difficult for the patient to lie still on the table, or any other co-morbidities that would support the need for the constant presence of an anesthesiologist or qualified anesthesia provider ( ASA 3 or ASA 4),

o Severe patient anxiety immediately prior to a procedure which may affect patient safety and comfort.

o Anticipated complexity to the planned standard procedures.

o Complications arising during the planned procedure or the inability to complete attempted interventional pain procedure in a patient who has received sufficient amounts of medications to induce minimal sedation.

o Medicare eligible pediatric patients.

 

 

Limitations

• Monitored anesthesia care performed solely based on the anesthetic being utilized or the patient’s age, except as indicated above, is not considered medically reasonable and necessary.

• Based on published peer reviewed literature and published guidelines, the performance of MAC is not considered the standard of care for interventional pain management services addressed in this LCD.

Coding Information

Bill Type Codes

• Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service.

• Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type.

• Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

 

 

13x Hospital Outpatient

85x Critical Access Hospital

 

 

Revenue Codes

• Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service.

• In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination.

• Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

 

0360 Operating Room Services - General Classification

0361 Operating Room Services - Minor Surgery

0362 Operating Room Services - Organ Transplant - Other than Kidney

0367 Operating Room Services - Kidney Transplant

0369 Operating Room Services - Other OR Services

0510 Clinic - General Classification

0511 Clinic - Chronic Pain Center

0512 Clinic - Dental Clinic

0513 Clinic - Psychiatric Clinic

0514 Clinic - OB-GYN Clinic

0515 Clinic - Pediatric Clinic

0516 Clinic - Urgent Care Clinic

0517 Clinic - Family Practice Clinic

0519 Clinic - Other Clinic

 

 

CPT/HCPCS Codes

 

01991 ANESTHESIA FOR DIAGNOSTIC OR THERAPEUTIC NERVE BLOCKS AND INJECTIONS (WHEN BLOCK OR INJECTION IS PERFORMED BY A DIFFERENT PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL); OTHER THAN THE PRONE POSITION

01992 ANESTHESIA FOR DIAGNOSTIC OR THERAPEUTIC NERVE BLOCKS AND INJECTIONS (WHEN BLOCK OR INJECTION IS PERFORMED BY A DIFFERENT PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL); PRONE POSITION

 

 

Documentation Requirements

• Medical record documentation must support the medical necessity of monitored anesthesia services and the number of minutes billed.

• In addition, all components of the anesthesia care including pre-anesthetic examination and evaluation, peri-anesthesia care, and post-anesthesia care must be documented in the patient’s medical record.

• This information is usually found in the hospital/office progress notes and anesthesia record.

• The following components must be included in the medical record:

o Pre-anesthesia evaluation – patient interview to include

 medical history,

 anesthesia history,

 medication history;

 appropriate physical exam;

 Review of objective diagnostic data (e.g., laboratory, electrocardiogram, x-ray, etc.);

 Assignment of physical status modifiers P3 or P4 (e.g., American Society of Anesthesiology physical status protocols);

 and

 Formulation and discussion of an anesthesia plan with the patient and/or responsible adult and patient’s attending physician.

o Peri-anesthesia (time based record of events) – immediate review prior to initiation of anesthetic procedure to include

 patient re-evaluation and check of equipment;

 monitoring of patient to include oxygenation,

 ventilation,

 circulation, and

 temperature (by qualified anesthesia personnel that is present in the room throughout the MAC);

 types, amounts and times of all drugs and agents with technique used including intravenous fluids and/or blood products;

 any unusual events during the monitoring period;

 and

 Status of patient at conclusion of anesthesia and procedure.

o Post-anesthesia – patient evaluation on admission and discharge from post-anesthesia;

 time-based record of vital signs and level of consciousness;

 types, amounts, and times of all drugs and agents administered;

 any unusual events including post-anesthesia or post-procedural complications;

 and

 Post-anesthesia visits and any follow-up prescribed.

o The interventional pain physician must document in the medical record why the patient’s clinical condition required MAC for the specific procedure performed.

 

 

Utilization Guidelines

• Interventional pain management procedures addressed in this LCD, generally do not require the addition of the physician services of MAC.

o Therefore, when MAC is utilized, the medical record must clearly support the medical reasonability and necessity describing why the patient’s condition requires the presence of a second physician or qualified anesthesia personnel to perform monitored anesthesia care in addition to the physician performing the procedure.

o This situation must be clearly outlined and documented in the patient’s medical record.

• The presence of an underlying condition alone, as reported by ICD-9 CM codes, is not sufficient evidence that MAC is medically reasonable and necessary.

o The patient’s medical condition must be significant enough to impact the need to provide MAC (such as the patient being on medication or being symptomatic, etc.).

o The presence of a stable, treated condition is not generally sufficient medical justification for MAC.

• When the patient’s condition does not meet medical necessity as outlined in the indications and limitations of this LCD, the provider must append the GA or GZ modifiers, as appropriate, along with the QS modifier.

o This will result in the appropriate denial of the services for the interventional pain management services as outlined above.

o MAC claims with the required QS modifier without the GA/GZ modifier should only be billed when MAC clearly meets the reasonable and necessary criteria for interventional pain injection procedures outlined in this LCD.

 

 

Sources of Information and Basis for Decision

 

American Society of Anesthesiologist, Distinguishing Monitored Anesthesia Care (“MAC”) from Moderate Sedation/Analgesia (Conscious Sedation). Approved by the ASA House of Delegates on October 27, 2004 and last updated on September 8, 2008.

 

American Society of Anesthesiologist, Guidelines for Office-Based Anesthesia. Approved by the ASA House of Delegates on October 13, 1999 and last affirmed on October 27, 2004.

 

American Society of Anesthesiologist Position on Monitored Anesthesia Care. Approved by the House of Delegates on October 21, 1986, amended on October 25, 2005 and last updated on September 2, 2008.

 

CareCore Pain Management. Pain Management Criteria 2009. Accessed via the web at www.carecore.com

 

Highmark Medicare Services, Inc, L27489 Local Coverage Determination for Monitored Anesthesia Care (MAC).

 

Trailblazer Health Enterprises, LLC, L 26520 Local Coverage Determination for Monitored Anesthesia Care (MAC).

 

01/01/2013

The official local coverage determination (LCD) is the version on the Medicare coverage database at www.cms.gov/medicare-coverage-database/.

 

 

AMA CPT / ADA CDT Copyright Statement

CPT codes, descriptions and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

 

 

CMS LCD MONITORED ANESTHESIA CARE (MAC) FOR CERTAIN INTERVENTIONAL PAIN MANAGEMENT SERVICES