Anesthesia Coding Alert

Simplify working with the surgical team to get the answers you need.

What do you do when your payer retires its monitored anesthesia care (MAC) policy, but you need to know how to support medical necessity for MAC? Follow this advice to help ensure you’re coding correctly and can back up your coding decisions.

Get Familiar With ASA Views

“Although many of the MAC policies have been retired, there is still a requirement for anesthesia services provided to any patient to be medically necessary,” says Kelly D. Dennis, MBA, ACS-AN, CANPC, CHCA, CPC, CPC-I, owner of Perfect Office Solutions in Leesburg, Florida.

Try this: Checking for guidance from the American Society of Anesthesiologists (ASA) will help improve your specialty knowledge and let you apply the best rationale to your coding. As an example, ASA “recognizes there are times when it may be necessary to provide moderate sedation or anesthesia care for pain procedures for adults and has outlined these in the ‘Statement on Anesthetic Care During Interventional Pain Procedures for Adults,’” available at www.asahq.org/standards-and-guidelines/statement-on-anesthetic-care-during-interventional-pain-procedures-for-adults, Dennis says.

The ASA statement explains that while interventional pain procedures generally require only local anesthesia, “significant patient anxiety and/or medical comorbidities may be an indication for moderate (conscious) sedation or anesthesia care team services.” Procedures where the patient must stay still for a long time or be in a painful position also “may require moderate sedation or anesthesia care team services,” the statement says, offering various procedure examples such as sympathetic blocks (celiac plexus, paravertebral, and hypogastric).

If a payer rejects a MAC claim for a service, you may be able to use a relevant ASA statement to support the medical necessity. You can show how the specifics of the patient’s case match the indications ASA lists for MAC.

Check Out Other Payers’ Policies

Even if your Medicare Administrative Contractor doesn’t currently have a monitored anesthesia care policy, you can look at other contractors’ policies to get a good idea of what might help support medical necessity, Dennis says.

Example 1: Check out Novitas Solutions’ local coverage article A57361, available by searching the Medicare Coverage Database (www.cms.gov/medicare-coverage-database/search.aspx), Dennis advises. The article includes helpful information like diagnoses that support medical necessity and documentation requirements. While the policy is specific to providers reporting to Novitas, the policy can be a helpful starting point if the payer you’re reporting to doesn’t have a policy of its own.

Example 2: Palmetto GBA recently posted “Anesthesia for Pain Management Procedures” to alert providers that “billing of moderate or deep sedation, general anesthesia, or MAC during a pain management procedure other than radiofrequency ablation will be denied. Frequent reporting of these services together may trigger focused medical review” (www.palmettogba.com/palmetto/jmb.nsf/DID/ VBQ9P37VM1#ls). Again, the information is specific to Palmetto claims, but knowing their position could give you some insight into areas other payers may be watching.

Streamline Getting Adequate Details From Surgeons

Coordinating with the surgical team will help with your goal of supporting MAC for a specific patient. One option is to have a worksheet that the surgeon’s team completes, explaining why the patient required MAC. Some examples of conditions to include on the worksheet to help support medical necessity are below (excerpt from Dennis’ “Monitored anesthesia care (MAC) worksheet example” at www.perfectofficesolutions. com/documents-to-download.html):

• Severe diabetes (e.g., blood sugar over 300)
• Morbid obesity (>200% ideal body weight)
• Organic brain syndrome/dementia with confusion or combative behavior
• Psychosis (psychiatric diagnosis and therapy)
• Other psych diagnosis (severe anxiety, panic disorder)
• Neurological disease
• Cardiac disease
• COPD
• Other severe pulmonary disease/stridor

The surgical team should include any details regarding the patient’s condition that will help with supporting medical necessity and assigning the appropriate diagnosis code.

Use Complete, Current ICD-10-CM Codes

To communicate medical necessity for MAC to payers, you must use the correct ICD-10-CM codes. That means codes that are complete (including every required character) and up to date. The effective date for the 2023 ICD-10-CM code set was Oct. 1, 2022, so you need to make sure your claims and resources are using the current codes.

Example: The specificity of dementia diagnosis codes increased drastically in the 2023 code set. Does your providers’ documentation support the level of specificity required to report the new codes? If not, meet with your providers to explain the new codes and increase their awareness of what the documentation requires. (See “Prepare Now for More Detailed Dementia Diagnosis Codes,” in Anesthesia Coding Alert, Volume 24, Number 9, to learn more about changes to dementia categories F01.- to F03.-.)

Also, the electronic health record (EHR) “templates providers are using may require updates. And lastly, any internal billing or charge systems will need to make the new codes available as of Oct. 1, 2022,” says Robin Peterson, CPC, CPMA, manager of professional coding services at Pinnacle Integrated Coding Solutions LLC in Centennial, Colorado.

Make Use of MAC Modifiers on Your Claim

After all the work you’ve done to support medical necessity for MAC, be sure to code the service correctly. CPT^® does not provide codes specific to MAC. Instead, the key is to use an appropriate modifier on the anesthesia code. Choose from these options:

• 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).