Wiki Need some clarification

[alk@APS]

I recently started coding for anes and I need a little clarification in regards to MAC and documentation. When billing MAC do you always need a diagnosis to justify its use? I have many colons/egds done with MAC, (Medicare and other carriers.) Sometimes I get a diagnosis on the anesthesia record that will say diabetes, hypertension, anxiety etc. Many times MAC is used and I only get the diagnosis for the procedure like a PEG tube placement with dyshagia. or I & D of left hand, diagnosis is infection, pt had a P4 status but I have no other diagnosis listed to support the MAC or the P4? I guess I need to know does MAC stand on it's own or do you always need to back up its use? Thanks

 

[dwaldman]

Might need to do a query regarding the P4 issue with the one who filled out the record you are reviewing. I usually use the Dx for the surgical procedure and it is the physician's who is ordering the sedation for procedure to document accordingly if this type of sedation might be in question for the procedure that is being performed.
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MAC "must be reasonable and medically necessary under the given circumstances. "

The instruction (underline emphasis added) states: Monitored anesthesia care involves the intraoperative monitoring by a physician, or by a qualified individual under the medical direction of a physician , of the patient s vital physiological signs, in anticipation of the needfor administration of general anesthesia or of the development of adverse physiological patient reaction to the surgical procedure. It also includes the performance of a pre-anesthetic examination and evaluation, prescription of the anesthesia care required, administration of any necessar oral or parenteral medications (e. , atropine, demerol, valium) and provision of indicated post-operative anesthesia care. The fact that the physician personally furnished or medically directed the monitored anesthesia care does not automatically mean the monitored anesthesia care is a covered page 2 Part B service. The monitored anesthesia car service must be reasonable and medically necessary under the given circumstaces.

http://oig.hhs.gov/oei/reports/oei-02-89-00050.pdf