Anesthesia Coding Alert

Check out this payer’s example of criteria to meet.

Although colonoscopy screening is a preventive care procedure that includes anesthesia, EGD procedures may still have requirements from insurance companies for medical necessity. If you are having difficulty, check for published clinical policy. For example, Amerigroup Partnership Plan, LLC publishes requirements for Monitored Anesthesia Care (MAC) as follows:

Monitored anesthesia care is considered medically necessary during gastrointestinal endoscopic procedures when there is documentation by the operating physician or the anesthesiologist that demonstrates any of the following higher risk situations exist:

• Prolonged or therapeutic endoscopic procedure requiring deep sedation such as endoscopic retrograde cholangiopancreatography (ERCP) or repeat colonoscopy due to tortuous colon; or
• A history of or anticipated poor response due to cross tolerance or paradoxical reaction to standard sedatives used during moderate (conscious) sedation specifically due to narcotics or benzodiazepines; or
• Increased risk for complication due to severe comorbidity (American Society of Anesthesi­ologists [ASA] class III physical status or greater. See Appendix for physical status classifications); or
• Individuals over 70; or
• Individuals under the age of 18; or
• Pregnancy; or
• History of drug or alcohol abuse; or
• Uncooperative or acutely agitated individuals (for example, delirium, organic brain disease, senile dementia); or
• Increased risk for airway obstruction due to anatomic variant including any of the following:​

            o History of previous problems with anesthesia or sedation; or
            o History of stridor or sleep apnea; or
            o Dysmorphic facial features, such as Pierre-Robin syndrome or trisomy-21; or
            o Presence of oral abnormalities including but not limited to a small oral opening (less than 3cm in an adult), high arched palate, macroglossia, tonsillar hypertrophy, or a non-visible uvula (not visible when tongue is protruded with individual in sitting position [for example, Mallampati class greater than II]); or
            o Neck abnormalities including but not limited to short neck, obesity involving the neck and facial structures, limited neck extension, decreased hyoid-mental distance (less than 3cm in an adult), neck mass, cervical spine disease or trauma, tracheal deviation, or advanced rheumatoid arthritis; or
            o Jaw abnormalities including but not limited to micrognathia, retrognathia, trismus, or significant malocclusion.

The routine assistance of an anesthesiologist or certified registered nurse anesthetist (CRNA) for individuals meeting the above criteria who are undergoing gastrointestinal endoscopic procedures is considered medically necessary.