Anesthesia Coding Alert

Hint: Pay attention to how anesthesia is administered.

Many anesthesia coders are accustomed to seeing "general" or "MAC (monitored anesthesia care)" when they comb through patient records for procedure details. Another term – TIVA – sometimes surfaces, so be sure you know what separates it from other anesthesia routes.

Learn the Basics of the Term

TIVA is another name for "total intravenous anesthesia." The American Society of Anesthesiologists Standards for Basic Anesthesia Monitoring classifies three types of anesthesia: 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.

Important: The term TIVA only tells how the provider administers the drugs, not the level of anesthesia he obtains. Because of this, physicians can use the TIVA technique to maintain any level of anesthesia – general or MAC.

Differentiate MAC from General

According to the ASA Relative Value Guide, "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."

Background: 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.

Know the CMS 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.

Clarify the Definition

Because TIVA can apply to either general anesthesia or MAC cases, you must understand the service so you can code correctly (especially when you’re required to submit MAC modifiers such as 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 cardio-pulmonary condition).

"I’ve heard some physicians say that TIVA equals general anesthesia, and others indicate it may mean MAC, depending on the patient’s level of consciousness," says Kelly Dennis, MBA, ACS-AN, CANPC, CHCA, CPC, CPC-I, owner of Perfect Office Solutions in Leesburg, Fl. "Some information online shows that TIVA is ‘between’ a MAC and general."

"Many coders don’t have a clinical background and should not be the one who determines whether the case was MAC or general when the notes indicate TIVA," Dennis adds. Talk to the physician or CRNA who documents TIVA to determine exactly what he or she means by the abbreviation. Be sure everyone in your group uses the abbreviation in the same way and that they note in the patient’s chart if a case moves from MAC or TIVA to general anesthesia.