Anesthesia Coding Alert

Plus: Remember it's a type of anesthesia, not just sedation level.

Monitored anesthesia care (MAC) is an area that can trip up coders, from newbies to those with years of experience. If you sometimes have trouble distinguishing MAC from moderate sedation, our experts recommend focusing on the patient's airway for the right answer every time.

Refresh Your MAC Knowledge

The American Society of Anesthesiologists (ASA) first published a position statement on MAC in 1986. The latest revision was in September 2008, with clarifications of terms such as "extended period of time" and "majority of the procedure."

MAC includes all aspects of anesthesia care: a pre-procedure visit, intraprocedure care, and post-procedure anesthesia management. Services during monitored anesthesia care can include:

• Diagnosis and treatment of clinical problems that occur during the procedure
• Support of vital functions
• Administration of sedatives, analgesics, hypnotics, anesthetic agents, or other mediations as necessary
• Psychological support and physical comfort
• Provision of other medical services as needed to safely complete the procedure.

MAC can include varying levels of sedation, depending on the circumstances. Because of that, the provider must be prepared -- and qualified -- to convert to general anesthesia if necessary.

Key: If the patient loses consciousness and the ability to respond purposely, you're no longer looking at MAC. Instead, the case is considered a general anesthetic, regardless of whether the patient requires airway instrumentation.

"If the patient loses consciousness, it's considered a general anesthetic, per the position statement," says Kelly Dennis, MBA, ACS-AN, CAN-PC, CHCA, CPC, CPC-I, owner of Perfect Office Solutions in Leesburg, Fl. "And remember for compliance purposes, the type of anesthesia indicated on the anesthesia record and in the operative report should be the same. I've seen several operative reports that indicate MAC and the anesthesia record indicates a general."

Distinguish MAC from Conscious Sedation

The biggest confusion for some coders lies in distinguishing MAC from moderate sedation/analgesia (also known as conscious sedation).

"What helps me is understanding these terms as a type of anesthesia, not a level of sedation," explains Leslie Johnson, CCS-P, CPC, manager of coding, compliance, and education for Somnia Anesthesia Services, Inc., in New Rochelle, N.Y. "Some procedures require a deeper level of sedation than others. Still, they follow the anesthesia protocols."

Example: Although the level of sedation may be "conscious," the type of anesthesia is MAC because the anesthesia provider is always ready to intervene for airway rescue or other types of rescue as needed.

Keep these comparisons in mind when you're faced with the MAC versus conscious sedation choice, based on explanations from the ASA:

• The provider offering moderate (conscious) sedation isn't expected to induce depths of sedation that would impair the patient's ability to maintain airway integrity. A MAC provider must be prepared to convert to general anesthesia, and be able to rescue the patient's airway from any sedation-induced compromise if necessary.
• Sedatives or other anesthetic drugs to induce or maintain general anesthesia are often a part of MAC, but are not required. The sedatives used for conscious sedation might be the same as those used for MAC, but usually are administered at a lower level.
• MAC allows "for the safe administration of a maximal depth of sedation in excess of that provided during moderate sedation."
• Both MAC and conscious sedation follow a plan of care for pre-, intra-, and postoperative administration. What differs is the practitioner who gives the sedation.
• Conscious sedation requires an independent observer and may have a "sedation" form rather than an anesthesia record.

"Typically, anesthesiologists provide anesthesia, not conscious sedation," Dennis adds. "An exception would be a pain management physician who performs the procedure and has an independent observer to monitor the patient during the procedure."

Next month: Sure-fire ways to finish your MAC claims with accurate documentation.