Anesthesia Coding Alert

Question: Our CRNA performed moderate sedation during an MRI. Is this a payable service? If so, do I need to include any anesthesia modifiers?

Michigan Subscriber

Answer: Since anesthesia is not typically required for an MRI, you should confirm the information and determine whether moderate sedation or Monitored Anesthesia Care (MAC) was provided to the patient. Usually, anesthesia providers are not requested for moderate sedation services, although it is not impossible. If moderate sedation applies, report the appropriate service. No modifier is necessary. If MAC was provided, you may need to report a QS (Monitored anesthesia care service), G8 (Monitored anesthesia care [MAC] for deep, complex, complicated, or markedly invasive surgical procedure), or G9 (Monitored anesthesia care for patient who has history of severe cardiopulmonary condition) modifier (as applicable and depending on the payer. If this was a pediatric patient, typically no additional diagnosis is necessary to explain the need for anesthesia. However, if this is an adult patient with medical necessity (for example, Parkinson's disease), you should report an additional diagnosis code to explain the need for anesthesia.