Anesthesia Coding Alert

Anesthesia care often involves administering medication in dosages that cause the patient to lose normal protective reflexes or that may lead to a loss of consciousness. Monitored anesthesia care (MAC), is the term used to describe situations when the patient remains able to protect his or her airway for the majority of the procedure, usually a diagnostic or therapeutic procedure such as a breast biopsy or colonoscopy. In this situation, an anesthesiologist may be requested to participate in the procedure in case the patient is ren-
dered unconscious and/or loses normal protective reflexes for an extended period of time.

A number of services are provided during MAC. These can include monitoring vital signs and maintaining the patients airway; diagnosing and treating clinical problems during the procedure, administering medications as necessary to ensure the patients safety and comfort, and providing other medical services as needed to safely complete the procedure.

Monitored anesthesia care is a physician service offered to an individual patient based on medical necessity, says Mike Scott, director of governmental and legal affairs at the American Society of Anesthesiologists (ASA). It should be reimbursed at the same level as general or regional anesthesia.

However, many Medicare carriers use a medical necessity policy that rejects claims for MAC for certain procedures, Scott says. For example, these carriers wont pay for codes 00100 (integumentary system of head and/or salivary glands, including biopsy) or 00400 (anterior integumentary system of chest, including subcutaneous tissue) unless a particular ICD-9 diagnostic code that supports medical necessity is also applied.

This non-reimbursement policy has been controversial for some carriers, because if a carrier doesnt reimburse for MAC procedures that fall under codes 00100 or 00400, women could theoretically undergo breast biopsies or other procedures covered by these codes without anesthesia. Codes 00100 and 00400 cover numerous procedures, some of which are truly minor and dont need MAC, says Karin Bierstein, ASAs practice management coordinator. But other procedures covered by those same codes should have anesthesia. Many carriers that initially adopted the rejection policy have reversed themselves or accepted modifications; most Medicare intermediaries should have a list of payable diagnoses for MAC that coders can use as a guide.

Putting New Modifiers in Place

The American Society of Anesthesiologists worked with the medical directors of the carriers that were still rejecting claims to come to an agreement on what would be acceptable to both parties, Scott continues. Our discussions led to HCFA sending a program memorandum to all carriers last spring that gives carriers the option of using two new modifiers that would indicate that MAC should be reimbursed in a specific case.

The two new modifiers are:

G8: MAC for deep, complex, complicated or other
markedly invasive surgical procedures on the face,
neck and breast (00100, 00400 and 00160), for
procedures for access to central venous circulation
(00532) and for procedures on male genitalia
(00920); and

G9: MAC for procedures performed for a patient
who has a history of severe cardiopulmonary
condition in order to prevent intraoperative
catastrophes.

These modifiers went into effect July 1, 1999, and will be included in HCPCS 2000. However, it is important to note that they are discretionary, so all carriers may not have adopted them.

Using the New Modifiers

If your carrier implements the new modifiers, they must be used in addition to the -QS modifier (MAC service), plus the appropriate anesthesia payment modifier for whether the procedure was personally performed or medically directed (-AA, -AD, -QY, -QX or -QZ). When MAC is provided, the anesthesia administration modifier should be placed first, followed by the procedure code -QS. The modifier must also be matched with an ICD-9 code that supports medical necessity. For example, if an anesthesiologist performs MAC unassisted, he or she would report the anesthesia service using the -AA modifier (anesthesia services performed personally by anesthesiologist) for payment purposes, and the -QS modifier for MAC.

Here are several examples that illustrate how the modifiers are used:

Example 1: If a CRNA performs MAC on a patient during a breast biopsy under the medical direction of an anesthesiologist, the procedure would be reported as 00400 (anesthesia for procedures on anterior integumentary system of chest, including subcutaneous tissue) for the breast biopsy, appended with modifiers -QX (CRNA service with medical direction by a physician), -QS (MAC) and
-G8 (MAC for deep, complex, complicated or other markedly invasive surgical procedure on the breast).

Example 2: If an anesthesiologist personally performs MAC on a patient during the insertion of an implantable central venous access device, the procedure would be reported as 00532 (anesthesia for access to central venous circulation), appended with modifiers -AA (anesthesia services performed personally by an anesthesiologist), -QS (MAC) and -G8 (MAC for procedures for access to central venous circulation).

Example 3: If an anesthesiologist performs MAC unassisted for a bronchoscopy with biopsy on a patient with a history of congestive heart failure, the procedure would be reported as 31625 (bronchoscopy; with biopsy), appended with modifiers -AA (anesthesia services performed personally by an anesthesiologist), -QS (MAC) and -G9 (MAC on a patient with a history of severe cardiopulmonary condition).

Example 4: If a member of an anesthesiology group performs MAC under the anesthesiologists medical direction during a cystourethroscopy on a patient who has had heart bypass surgery, the procedure would be reported as 52000 (cystourethroscopy [separate procedure]), appended with modifiers -AB (medical direction of own employees by an anesthesiologist), -QS (MAC) and -G9 (MAC on a patient with a history of severe cardiopulmonary condition).

Marybel Ortega, CPC, an anesthesia coding supervisor with Medaphis Physician Services Corporation in Miami, a medical billing service for anesthesia, radiology and hospital outpatient services, stresses the importance of checking with your state carriers to see if the new modifiers are accepted. I checked with my local Medicare contacts and was told that we are not affected by the new modifiers in Florida, she says. For the states that are accepting the new modifiers, I would think that they would go through without any problems. There arent any unusual notations to include, so its just a matter of adding the new modifier to the others that describe the procedure.

Whether a particular state accepts the new modifiers or not, Ortega points out that it is important that coders not confuse standby anesthesia with monitored anesthesia. Medicare Part B doesnt cover the services of a standby anesthesiologist, she says. That makes it even more important to document the surgeons request for MAC as well as the patients medical necessity. If youre not sure whether a procedure will be classified as standby or
MAC, talk with your local carrier.

Many state anesthesiology societies have a Carrier Advisory Committee (CAC) to advise local insurance carriers of Medicare regulations, to make recommendations about local medical necessity policies and to institute uniform practice guidelines. If the MAC medical necessity policy is in effect in your area, Bierstein recommends that you contact the anesthesiologist who represents you on the CAC to be sure your carriers medical director accepts the modifiers. Call your state anesthesiology society to get the name of your CAC representative. If your state doesnt have a CAC, your areas Medicare/Medicaid or practice management representative should be able to tell you more about the new modifiers and whether they apply in your area.