Anesthesia Coding Alert

Question: I was always under the impression that total intravenous anesthesia (TIVA) was considered general, but I have heard recently that some payers consider TIVA to be monitored anesthesia care (MAC). Which is correct? How can I identify MAC services?

Delaware Subscriber

Answer: Whether TIVA is general or MAC should be determined and documented by your anesthesiologist.

There are three types of anesthesia, according to the American Society of Anesthesiologists (ASA) Standards for Basic Anesthesia Monitoring: general, regional and MAC. TIVA refers to how a drug is given and means all anesthetic drugs were given by IV, not inhalation. These drugs can be given to provide MAC or general, depending on the dose concentration and type.

MAC details:  The ASA's Position on MAC, which was last updated in 2013, states, "Monitored anesthesia care is a specific anesthesia service for a diagnostic or therapeutic procedure. Indications for monitored anesthesia care include the nature of the procedure, the patient's clinical condition and/or the potential need to convert to a general or regional anesthetic."

Heads up: Previously, anesthesia services fell into three categories: general, regional and local standby. The ASA later created the term «monitored anesthesia care» to replace «standby anesthesia.» Experts believed MAC better described situations in which your anesthesiologist provides care but the patient does not need general or regional anesthesia. Today, MAC refers to times when your anesthesiologist records face-to-face time and performs a service. Standby refers to situations in which your anesthesiologist is available but not present with the patient, or is in the room but not monitoring the patient.

Keep up with CMS MAC rules: In the Medicare Claims Processing Manual, CMS states that anesthesiologists use modifier QS (Monitored anesthesia care service) to report MAC cases. "Monitored anesthesia care involves the intra-operative monitoring by a physician or qualified individual under the medical direction of a physician or of the patient's vital physiological signs in anticipation of the need for administration of general anesthesia or of the development of adverse physiological patient reaction to the surgical procedure." MAC includes a pre-anesthetic examination and evaluation, prescription of the anesthesia care required, administration of any necessary oral or parenteral medications (such as Atropine, Demerol, Valium) and any indicated postoperative anesthesia care. As this is an anesthetic -- unlike conscious sedation – all aspects of anesthesia monitoring and patient care are necessary.

Tip: If applicable, check your Local Coverage Determination (LCD) to determine whether G8 or G9 will override the QS modifier based on the procedure or patient's condition.