Coverage Policies

Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

1)    With advances in modern medical technology, there has been a shift in supplying some surgical and diagnostic services to an ambulatory, outpatient, or office setting. Accompanying this, there has been a change in the provision of anesthesia services from the traditional general anesthetic to a combination of local, regional, and certain mind altering drugs.  This type of anesthesia is referred to as monitored anesthesia care (MAC) if directly provided by anesthesia personnel.

2)    MAC requires careful and continuous evaluation of various vital physiologic functions and the diagnosis and treatment of any deviations.  This type of anesthesia can be provided by a variety of qualified anesthesia personnel.

3)    When provided for a service that does not usually require anesthesia, such as colonoscopy, esophagoscopy and cystoscopy, MAC is subject to medical review.

1)    In keeping with the American Society of Anesthesiologists` standards for monitoring, MAC should be provided by qualified anesthesia personnel (anesthesiologists or qualified anesthetists such as certified registered nurse anesthetists).  These individuals must be continuously present to monitor the patient and provide anesthesia care.  

2)    During MAC, the patient`s oxygenation, ventilation, circulation and temperature should be evaluated by whatever method is deemed most suitable by the attending anesthetist.  

3)    The requirements for this type of anesthesia are the same as for general anesthesia with regard to the performance of pre-anesthetic examination and evaluation, prescription of the anesthesia care required, the completion of an anesthesia record, the administration of necessary oral or parenteral medications, and the provision of indicated post-operative anesthesia care.  Appropriate documentation must be available to reflect pre- and post-anesthetic evaluations and intraoperative monitoring.

4)    Reimbursement for MAC will be the same amount allowed for full general anesthesia services if all the requirements are met.

5)    For services that do not usually require anesthesia, MAC will be covered only when the patient’s condition is at such risk as to require presence of anesthesia personnel to monitor.

6)    MAC for GI procedures is only covered when:

a)    When anesthesia for upper GI endo procedures (00731 or 00732) are billed in outpatient hospital or ambulatory surgical center setting on a member with severe systemic disease (with modifier P3 or P4) and with esophagoscopy codes 43191-43206 or 43215-43232.

b)    When anesthesia for Endoscopic Retrograde Cholangiopancreatography (ERCP, 00732) is billed in outpatient hospital or ambulatory surgical center setting on a member with severe systemic disease (with modifier P3 or P4) and ERCP codes 43260-43265.

c)    When anesthesia for colonoscopy (00811 or 00812) in outpatient hospital or ambulatory surgical center setting on a member with severe systemic disease (with modifier P3 or P4) and colonoscopy codes 45378-45388.

7)    When anesthesia combined for upper & lower GI endo endoscopy (00813) is billed with POS 22 or 24 with modifier P3 or P4 and both upper endoscopy codes 43191-43206 or 43215-43232 AND lower endoscopy 45378-45388

Codes Used In This BI: