Highmark Medicare Services

12102, 12202, 12302

MAC Part A & B

L27489

Monitored Anesthesia Care (MAC)

L27489

CPT codes, descriptions and other data only are copyright 2007 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.

Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no Medicare payment shall be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury.

Title XVIII of the Social Security Act, Section 1862(a)(7). This section excludes routine physical examinations.

Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim.

CMS On-line Manual Pub. 100-4, Chapter 12, Section 50.

Maryland, District of Columbia, Delaware

Central Office

For services performed on or after 07/11/2008

N/A

For services performed on or after N/A

N/A

Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis and subsequent medical review audits.

The following Indications and Limitations are pertinent to any and all Monitored Anesthesia Care (MAC) services in general, regardless of the procedure performed or the anesthesia drug(s) administered.

With advances in modern medical technology, there has been a shift in supplying some surgical and diagnostic services to an ambulatory, outpatient or office setting. Accompanying this, there has been a change in the provision of anesthesia services from the traditional general anesthetic to a combination of local, regional and certain mind-altering drugs. Monitored Anesthesia Care (MAC) requires careful and continuous evaluation of various vital physiological functions and the diagnosis and treatment of any clinical observations or deviations. MAC can be provided by a variety of qualified anesthesia personnel. However, such personnel must have training and experience involving:

• patient assessment
• continuous evaluation and monitoring of patient physiological functions
• diagnosis and treatment (both pharmacological and non-pharmacological) of any and all deviations in physiological functions.

Also, adequate medical and pharmacological equipment must be readily available at all times during MAC.

Coverage for MAC is allowed only when all of the following are satisfied:

• the service is properly coded
• documentation is clear and all documentation requirements are met
• the service is reasonable and necessary
• the facility requirements are met

MAC must be provided by qualified anesthesia personnel. These individuals must be continuously present to monitor the patient and provide anesthesia care.

During MAC, the patient's oxygenation, ventilation, circulation and temperature (for those patients at risk for hypothermia or malignant hyperthermia) should be evaluated by whatever method is deemed most suitable by the attending anesthetist. Close monitoring is necessary to anticipate the need for general anesthesia administration or for the treatment of adverse physiologic reactions such as hypotension, excessive pain, difficulty breathing, arrhythmias, adverse drug reactions, etc. In addition, the possibility that the surgical procedure may become more extensive, and/or result in unforeseen complications, requires comprehensive monitoring and/or anesthetic intervention.

During monitored anesthesia care, the attending anesthetist must provide a number of specific services, including but not limited to all of the following:

• Pre-procedure visit and evaluation
• Intraprocedure monitoring of patient's vital signs, maintenance of the patient's airway and continual evaluation of vital functions
• Diagnosis and treatment of any clinical problems which occur during the procedure
• Administration of sedatives, analgesics, hypnotics, anesthetic agents or other medications as necessary to ensure patient safety and comfort
• Provision of medical services as needed to accomplish the safe completion of the procedure
• Post-procedure anesthesia management

Facility-Equipment Requirements

The following facility and equipment requirements encourage quality patient care, but observing them cannot guarantee any specific patient outcome. These requirements pertain to any and all MAC services performed.

• MAC location must have a reliable source of oxygen adequate for the length of the procedure. There must also be a backup supply.

• MAC location must have an adequate and reliable source of suction. Suction apparatus that meets operating room standards is encouraged.

• MAC locations in which inhalation anesthetics are administered must have an adequate and reliable system for scavenging waste anesthetic gases.

• Each MAC location must include:
  
  

  1. a self-inflating hand resuscitator bag capable of administering at least 90 percent oxygen as a means to deliver positive pressure ventilation

  2. adequate anesthesia drugs, supplies and equipment for the intended anesthesia care, and

  3. adequate monitoring equipment to allow for all patient monitoring noted in documentation requirements
     
  4. each MAC location shall have immediately available an emergency cart with defibrillator, emergency drugs and other equipment adequate to provide cardiopulmonary resuscitation

The Centers for Medicare and Medicaid Services (CMS) requirements for this type of anesthesia are the same as for general anesthesia. Specifically, the requirement includes the performance of pre-anesthetic examination and evaluation, prescription of the anesthesia care required, the completion of the anesthesia record, the administration of necessary oral or parenteral medications and the provision of indicated post-operative anesthesia care. Appropriate documentation must be available to reflect the pre and post-anesthetic evaluations and intraoperative monitoring.

Reimbursement for MAC will be the same amount allowed for full general anesthesia services if all the requirements listed under these indications are met. The provision of quality MAC is mandatory and requires the same expertise and the same effort (work) as required in the delivery of a general anesthetic. If the requirements are not fulfilled or the procedures are unnecessary, payment will be denied in full.

The MAC service rendered must be reasonable, appropriate and medically necessary. The presence of an underlying condition alone, as reported by an ICD-9 code, may not be sufficient evidence that MAC is necessary. The medical condition must be significant enough to impact on the need to provide MAC such as the patient being on medication or being symptomatic, etc. The presence of a stable, treated condition in and of itself is not necessarily sufficient.

The codes listed in the "CPT/HCPCS Codes" section of this policy illustrate procedures that do not usually require anesthesia services. However, MAC may be covered when the patient's condition requires the presence of qualified anesthesia personnel to perform monitored anesthesia in addition to the physician performing the procedure. The necessity for the MAC service must be clearly reflected in the medical record.

The anesthesia procedures listed in the "CPT/HCPCS Codes" section of this policy are usually provided by the attending surgeon, are included in the global fee, and are not usually separately reimbursable. However, in certain instances, MAC provided by anesthesia personnel may be necessary for these procedures, if the patients' diagnosis or pertinent medical history is reflective of one or more of the conditions found in the "ICD-9 Codes That Support Medical Necessity" section of this policy.

Also, the following indications/conditions will be considered on an individual basis when reported for one of the services listed in the "CPT/HCPCS Codes" section of this policy. Documentation to support the medical necessity of the service must be maintained in the patient's clinical record. For coding guidelines specific to the indications/conditions listed below, refer to the corresponding article for Monitored Anesthesia Care (MAC) (to follow).

• Combative patients

• Patients with low pain thresholds or who suffer severe pain

• Intraoperative expansion of procedure

• Any condition in a pediatric patient, Medicare eligible

• Mental retardation (e.g., patients who are uncooperative due to a lack of understanding caused by their mental disability)

• The administration of certain anesthetic drugs that require the expertise of an M.D., D.O. (not directly performing the surgical/diagnostic procedure) or a CRNA (e.g., propofol, fentanyl, versed, diprivan, stadol)

In summary, MAC may be necessary and justified for the HCPCS codes listed in the "CPT/HCPCS Codes" section of this policy to insure safety by the prevention of adverse physiologic complications. When reporting services that do not usually require MAC, append the appropriate anesthesia modifier and the QS modifier (when a co-existing condition the "ICD-9 Codes That Support Medical Necessity" exists).

Limitation

Any MAC service reported not meeting the guidelines outlined in the "Indications and Limitations of Coverage and/or Medical Necessity" section of this LCD.

Anesthesia (Inpatient), Anesthesia (Outpatient)

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.

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.

N/A

All those not listed under the “ICD-9 Codes that Support Medical Necessity” section of this policy.

Conditions that are not listed in the "ICD-9-CM Codes that Support Medical Necessity" section of this policy.

1. All documentation must be maintained in the patient’s medical record and available to the contractor upon request.
   
2. Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service(s)).  The record must include the physician or non-physician practitioner responsible for and providing the care of the patient.
   
3. The submitted medical record should support the use of the selected ICD-9-CM code(s).  The submitted CPT/HCPCS code should describe the service performed.

The following Documentation Requirements are pertinent to any and all Monitored Anesthesia Care (MAC) services in general, regardless of the procedure performed or the anesthesia drug(s) administered.

Clear and complete documentation is a factor in the provision of quality care. Supportive documentation is the responsibility of the anesthetist, and mandatory for Medicare coverage and reimbursement. While anesthesia care is a continuum, it is viewed as consisting of preanesthesia, perianesthesia and postanesthesia components. Monitored anesthesia care (MAC) must be documented to include the following:

I. Pre-anesthesia evaluation

1. Patient interview to include medical history, anesthesia history, medication history

2. Appropriate physical exam

3. Review of objective diagnostic data (e.g., laboratory, ECG, X-ray)

4. Assignment of physical status (e.g., ASA physical status protocols)

5. Formulation and discussion of an anesthesia plan with the patient (and/or responsible adult) and patient's attending surgeon

II. Perianesthesia (time-based record of events)

1. Immediate review prior to initiation of anesthetic procedure:
   1. Patient re-evaluation
   2. Check of equipment, drugs, gas supply

2. Monitoring of the patient
   1. Qualified anesthesia personnel shall be present in the room throughout MAC
   2. The patient's oxygenation, ventilation, circulation, and temperature shall be continually evaluated.

3. Amounts of all drugs and agents used, and times given

4. The type and amounts of any/all intravenous fluids used, including blood and blood products, and times given

5. The technique(s) used

6. All unusual events during the anesthesia-monitoring period

7. Status of patient at conclusion of anesthesia and procedure

III. Postanesthesia

1. Patient evaluation on admission and discharge from postanesthesia

2. A time-based record of vital signs and level of consciousness

3. All drugs administered and their dosages

4. Types and amounts of intravenous fluids administered

5. Any unusual events including postanesthesia or postprocedural complications

6. Postanesthesia visits and any follow-up prescribed

When reporting MAC for one of the procedures listed in the "CPT/HCPCS Codes" section of this policy, the presence of an underlying condition alone, as reported by an ICD-9 code, may not be sufficient evidence that MAC is necessary. The medical condition must be significant enough to impact on the need to provide MAC and be clearly reflected in the medical record.

Services that usually do not require MAC and are not supported by an underlying condition represented in the "ICD-9 Codes That Support Medical Necessity" section of this policy, may be reviewed on an individual consideration basis. All supporting documentation must be forwarded to the contractor upon request.

ICD-9 V58.83 (Encounter for therapeutic drug monitoring) should be used when patient provided MAC monitoring secondary, or integral, to use of drugs such as propofol, versed, etc.

In accordance with CMS Ruling 95-1(V), utilization of this service(s) should be consistent with locally acceptable standards of practice.

AANA-ASA Joint Statement Regarding Propofol Administration*

April 14, 2004

American Medical Association, Current Procedural Terminology; CPT 2000

American Society of Gastrointestinal Endoscopy, publication #1016

ASA Position on Monitored Anesthesia Care (Approved by the ASA House of Delegates on October 21, 1998), December 1998 Volume 62

Carrier Medical Director's Workgroup Template policy

Douglas B. Coursin MD, Gerald A. Maccioli MD, FCCM, Michael J. Murray MD, PHD, FCCM, Perioperative Medicine; Anesthesiology Clinics Of North America Volume 18 o Number 3 o September 2000

J. Heine, K. Jaeger, A. Osthaus, N. Weingaertner, S. Münte, S. Piepenbrock and M. Leuwer, Anaesthesia with propofol decreases FMLP-induced neutrophil respiratory burst but not phagocytosis compared with isoflurane; British Journal of Anaesthesia, 2000, Vol. 85, No. 3 424-430

Leffler TM, Propofol for sedation in the endoscopy setting: nursing considerations for patient care; Gastroenterol Nurs. 2004 Jul-Aug;27 (4):176-80

Medicode ICD-9, 1999

Practice Guidelines For Sedation And Analgesia By

Non-Anesthesiologists, (Approved By The House Of Delegates On October 25, 1995, And Last Amended On October 17, 2001) An Updated Report By The American Society Of Anesthesiologists Task Force On Sedation And Analgesia By Non-Anesthesiologists

Practice Guidelines for Acute Pain Management in the Perioperative Setting

(Approved by the House of Delegates on October 16, 1994, and last amended on October 15, 2003), Developed by the American Society of Anesthesiologists Task Force on Acute Pain Management

The American Society of Anesthesiologists, Inc.; Practice Guidelines

Tung A., New anesthesia techniques; Thorac Surg Clin. 2005 Feb;15 (1):27-38.

Xin-sheng Deng M.D. Victoria J. Simpson M.D., Ph.D. and Richard A. Deitrich Ph.D., Department of Pharmacology, Nitric oxide and Propofol University of Colorado Health Sciences Center, Denver, Colorado, USA 80262

Other Contractors' Policies

Highmark Medicare Services Contractor Medical Directors

This policy does not reflect the sole opinion of the contractor or Contractor Medical Director. Although the final decision rests with the contractor, this policy was developed in cooperation with advisory groups that include representatives from Anesthesiology.

CAC/IAC Distribution:  04/01/2008

05/15/2008

05/23/2008

L27489

05/22/2008

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