# Monitored anesthesia by CRNA in outpatient setting



## srouleau (Jan 25, 2012)

I work in an outpatient MRI facility and we occasionally have a CRNA that will provide monitored anesthesia care w/IV sedation for our claustrophobic patients.  How should this be coded?  I have been using 99144 and 99145 with the QX modifier but we want to know if there is another way this should be done.  I would appreciate any input on this matter!  Thanks!


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## srouleau (Mar 8, 2012)

I have yet to be able to figure this out.  Any assistance would be greatly appreciated.  My CRNA is not happy with what we have been doing.


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## aaron.lucas (Mar 9, 2012)

If you're doing MAC then you shouldn't be using the conscious sedation codes, is the patient awake?  If not, and they're completely out, then you would probably want to use 01999 (since there doesnt seem to be an anesthesia code for MRI's) with modifier QX, and then the MRI should be billed with modifier 23 to show the unusual anesthesia (MRI normally doesnt need it).  Actually come to think of it, is the CRNA doing this alone, without supervision?  if so then you would use modifier QZ on the MAC code, not QX.  Now of course if the patient IS awake then the moderate sedation codes would be correct, but I think you would still put modifier 23 on the MRI code to show that there was unusual anesthesia.  also dont forget to document the reason why.  hope this helps!


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## meganrveach (Mar 9, 2012)

My crosswalk coder shows 01922 for anesthesia for MRI's.  You will need to calculate the Anesthesia time, Base unit and ASA classification to figure out your units to bill and use the QZ modifier since the CRNA is in attendance without an anesthesiologist directing. Hope this helps!


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## aaron.lucas (Mar 9, 2012)

I'll be darned I was reading that wrong.  Ok then I agree, 01922-QZ, and dont forget the -23 for the MRI code.


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## srouleau (Mar 9, 2012)

We are sedating claustrophobic patients and patients that are in too much pain to lie still in the MRI/CT machines as they require you to be completely still to get good images.  They usually just receive Versed or Valium.  The patients do occasionally fall asleep but that is not our intention.  So, with that being said, would I still use a 019...code and the 23 modifier (for the MRI/CT) or would 99143-99145 suffice?  One more thing, our CRNA is under the supervision of an MD but he is not an anesthesiologist so would this still be the QX modifier?  Thanks again for any input.


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## aaron.lucas (Mar 9, 2012)

OH ok, well in that case...actually is the CRNA doing the MRI as well?  Cause it says in the guidelines:  When a second physician other than the healthcare professional performing the dx or therapeutic services provides moderate sedation in the nonfacility setting (drs office or freestanding imaging center), then codes 99148-99150 are not reported.  and if the CRNA isn't doing the MRI then you cant use 99143-99145 either cause that's only for the same person.  you may not be able to bill for it at all under the circumstances.


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## srouleau (Mar 9, 2012)

No, we have technologists that perform the MRI so the CRNA is only giving the sedation and taking vitals and all that for the patient.


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## missyah20 (Mar 13, 2012)

Here is a good article from the ASA on Distinguishing MAC from Moderate Sedation. This article can be found on the AMA website and in the Relative Value Guide.  Of course, the CRNA should be stating what type of anesthesia is being administered on the anesthesia record.

DISTINGUISHING MONITORED ANESTHESIA CARE (“MAC”) FROM MODERATE SEDATION/ANALGESIA (CONSCIOUS SEDATION)
Committee of Origin: Economics
(Approved by the ASA House of Delegates on October 27, 2004 and last amended on
October 21, 2009)
Moderate Sedation/Analgesia (Conscious Sedation; hereinafter known as Moderate Sedation) is a physician service recognized in the CPT procedural coding system. During Moderate Sedation, a physician supervises or personally administers sedative and/or analgesic medications that can allay patient anxiety and control pain during a diagnostic or therapeutic procedure. Such drug-induced depression of a patient’s level of consciousness to a “moderate” level of sedation, as defined in the Joint Commission (TJC) standards, is intended to facilitate the successful performance of the diagnostic or therapeutic procedure while providing patient comfort and cooperation. Physicians providing moderate sedation must be qualified to recognize “deep” sedation, manage its consequences and adjust the level of sedation to a “moderate” or lesser level. The continual assessment of the effects of sedative or analgesic medications on the level of consciousness and on cardiac and respiratory function is an integral element of this service.

The American Society of Anesthesiologists has defined Monitored Anesthesia Care (see Position on Monitored Anesthesia Care, updated on September 2, 2008). This physician service can be distinguished from Moderate Sedation in several ways. An essential component of MAC is the anesthesia assessment and management of a patient’s actual or anticipated physiological derangements or medical problems that may occur during a diagnostic or therapeutic procedure. While Monitored Anesthesia Care may include the administration of sedatives and/or analgesics often used for Moderate Sedation, the provider of MAC must be prepared and qualified to convert to general anesthesia when necessary. Additionally, a provider’s ability to intervene to rescue a patient’s airway from any sedation-induced compromise is a prerequisite to the qualifications to provide Monitored Anesthesia Care. By contrast, Moderate Sedation is not expected to induce depths of sedation that would impair the patient’s own ability to maintain the integrity of his or her airway. These components of Monitored Anesthesia Care are unique aspects of an anesthesia service that are not part of Moderate Sedation.

The administration of sedatives, hypnotics, analgesics, as well as anesthetic drugs commonly used for the induction and maintenance of general anesthesia is often, but not always, a part of Monitored Anesthesia Care. In some patients who may require only minimal sedation, MAC is often indicated because even small doses of these medications could precipitate adverse physiologic responses that would necessitate acute clinical interventions and resuscitation. If a patient’s condition and/or a procedural requirement is likely to require sedation to a “deep” level or even to a transient period of general anesthesia, only a practitioner privileged to provide anesthesia services should be allowed to manage the sedation. Due to the strong likelihood that “deep” sedation may, with or without intention, transition to general anesthesia, the skills of an anesthesia provider are necessary to manage the effects of general anesthesia on the patient as well as to return the patient quickly to a state of “deep” or lesser sedation.

Like all anesthesia services, Monitored Anesthesia Care includes an array of post-procedure responsibilities beyond the expectations of practitioners providing Moderate Sedation, including assuring a return to full consciousness, relief of pain, management of adverse physiological responses or side effects from medications administered during the procedure, as well as the diagnosis and treatment of co-existing medical problems.

Monitored Anesthesia Care allows for the safe administration of a maximal depth of sedation in excess of that provided during Moderate Sedation. The ability to adjust the sedation level from full consciousness to general anesthesia during the course of a procedure provides maximal flexibility in matching sedation level to patient needs and procedural requirements. In situations where the procedure is more invasive or when the patient is especially fragile, optimizing sedation level is necessary to achieve ideal procedural conditions.

In summary, Monitored Anesthesia Care is a physician service that is clearly distinct from Moderate Sedation due to the expectations and qualifications of the provider who must be able to utilize all anesthesia resources to support life and to provide patient comfort and safety during a diagnostic or therapeutic procedure.


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## missyah20 (Mar 13, 2012)

Sorry - ASA not AMA Website:  Here is a link: http://www.asahq.org/For-Members/Standards-Guidelines-and-Statements.aspx


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## MichelleStansifer (Aug 15, 2013)

*MAC - Time/Monitoring Requirements*

When a CRNA is providing MAC during a procedure, when does the "time" start? When she is interviewing the patient or when drug is started? 

Also, if she is billing 1100 to 1120 for example; does she have to be with the patient monitoring the patient the entire time? Can she have another case starting at 1118? 

Thanks, 
Michelle


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