Anesthesia Coding Alert

Coding routine versus deep sedation for gastrointestinal (GI) procedures is challenging because carriers descriptions of the physical conditions and diagnoses associated with the procedure vary as do their coding and documentation requirements. Monitored anesthesia care (MAC), used in procedures that do not normally require anesthesia, includes the patients preanesthetic exam, evaluation and postoperative care.

Medicare defines MAC as intraoperative monitoring of patients vital signs in anticipation of a need for general anesthesia or the development of adverse physiological reaction to the surgical procedure. Coders should bill the applicable anesthesia code with modifier -QS (monitored anesthesia care service) attached, according to Medicare Carriers Manual 52018.

You would code a procedure MAC if it required deep sedation and monitoring for vital signs or complications, says Theresa Ruiz-Law, director of managed care and reimbursement for the American Association of Nurse Anesthetists. But dont use MAC for routine situations, such as conscious sedation for colonoscopies or upper GI endoscopies because Medicare will deny it. Carriers in many states, such as New York, assume sedation for endoscopies is standard anesthesia and is included in the fee for the endoscopy procedure.

Be Aware of Carrier Policies for MAC Coding

To provide more detail in addition to modifier -QS, you can append two other HCPCS modifiers, depending on the patients situation and local carrier requirements. Modifier -G8 designates monitored anesthesia care (MAC) for deep complex, complicated, or markedly invasive surgical procedure, while modifier -G9 indicates monitored anesthesia care for patient who has history of severe cardio-pulmonary condition. For example, you would code anesthesia for a lower endoscopy performed with MAC as 00810-QS (anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum; MAC service). You would, however, include modifier -G9 if the patients history necessitated it and if the local carrier requires it.

When HCFA introduced the -QS modifier, it said that physician reimbursement for procedures using MAC would not be affected; reimbursement would remain the same. Medicares only reason for establishing this modifier is to track MAC cases so they can formulate a reimbursement policy, says Mark DiDonato, manager of practice activities for the department of anesthesiology at Thomas Jefferson University Hospital in Philadelphia. Medicare might be making plans, but a number of states have already established these types of policies, and DiDonato believes that others are moving in that direction.

File Separate Claims for Reimbursement

Patient conditions and the facility where the procedure was performed also influence a carriers decision to accept separate claims for MAC. Medicare defines a number of conditions that might merit MAC during endoscopic procedures, according to Ruiz-Law. Acute renal failure; severe cardiopulmonary disease; uncontrolled hypertension; life-threatening arrhythmias; and deep, complex, complicated invasive procedures for the face, neck, and breast are on the list. Acute medical problems, such as active angina, GI bleeding, mental retardation or the patients age can help justify the need for MAC during the procedure. If youre going to use patient condition to get reimbursed for MAC, youll have to provide strong case details in your supporting documentation.

Patient condition also often determines where a physician performs a procedure. And that, in turn, can influence reimbursement. In its allowances Medicare considers the location of a procedure whether its performed in a facility or an office (termed as facility or nonfacility). For example, the office might be the appropriate setting to perform a colonoscopy on a relatively low-risk patient. In this case, Medicare and some commercial carriers would consider the sedation as part of the procedure and will not pay separately.

However, GI procedures that might require MAC (most often performed on higher-risk patients in an ambulatory surgery center or hospital) are billable separately. Its important to note that, because of the associated costs, the physician billing for services in an
office setting would get paid slightly more for the procedure itself than if it had been performed in a facility.

Justify MAC With Documentation

If the GI procedure requires MAC, youll need to document its use with:

A written request from the surgeon asking for MAC anesthesia;

Clear documentation of the patients diagnosis and status that will justify the need for MAC; and

Thorough pre-op and post-op evaluations by the anesthesia provider and charts of the patients care, vital signs, and circumstances that prove MAC was administered.

This detailed documentation will not only facilitate reimbursement, it will also help defend an appeal if a carrier denies the initial request for MAC payment.

Code MAC or Bundle Anesthesia With Procedure

Coding is fairly straightforward when a surgeon provides sedation. Depending on the method of administration, appropriate codes would be 99141 (sedation with or without analgesia [conscious sedation]; intravenous, intramuscular or inhalation) or 99142 ( oral, rectal and/or intranasal) with an independent trained observer providing the monitoring when the physician administers the sedative.

Medicare bundles the sedation payment under the operating physicians fee, Ruiz-Law explains. If the procedure was performed with sedation that doesnt have documentation to prove medical necessity, Medicare will not reimburse, and the anesthesia provider wont be paid.

Note: If the anesthesiologist administers the sedation, the appropriate anesthesiology code would vary with the procedure (e.g., colonoscopy or lower endoscopy).

Never Make Assumptions

Carriers are more closely examining and monitoring how providers use MAC. A lot of Medicare carriers now are doing pre- and postpayment reviews on MAC cases to determine its medical necessity and the level of involvement of the anesthesiologist or other trained anesthetist, DiDonato explains. The coding caution? Dont assume a particular carrier that paid you for a MAC-involved procedure yesterday will do the same today or tomorrow. As always, check with your local carrier to make sure you meet its guidelines for reimbursement.