Anesthesia Coding Alert

Question: Does the anesthesia record have to state when the type of anesthesia was MAC? I have always thought it was required to be in the documentation, but a coworker disagrees.

New Mexico Subscriber

Answer: You are correct – the type of anesthesia should always be documented in your provider’s record. This requirement is noted in the ASA Statement of Documentation of Anesthesia Care. Joint Commission International Accreditation Standards for Hospitals also states, “Each patient’s anesthesia care is planned and documented, and the anesthesia and technique used are documented in the patient’s medical record.”

Although it’s clinical information rather than billing information, it needs to be documented so billers and coders can file correctly. If you ever have a case that doesn’t include the information, you’ll need to alert the anesthesia practitioner and ask for clarification.

You can find clues when your providers administer blocks and general anesthesia, but unfortunately aren’t able to discern when monitored anesthesia care (MAC) is used unless they specify it in the anesthesia record. Remember that looking at the anesthesia plan is a good guide, but the record is what documents what actually occurred.

When you report MAC, append the appropriate modifiers:

• QS, Monitored anesthesia care service
• G8, Monitored anesthesia care (MAC) for deep complex, complicated, or markedly invasive surgical procedure
• G9, Monitored anesthesia care for patient who has history of severe cardio-pulmonary condition

Modifier QS should always be reported when the anesthesia provider’s services meet the definition of monitored anesthesia care; modifiers G8 and G9 are used when dictated by the circumstances. Remember that modifiers G8 or G9 will override a QS modifier, when applicable.

Remember: MAC refers a combination of a local anesthetic with sedation generally administered by a provider who is qualified to provide general anesthesia.