Billing and Coding: Monitored Anesthesia Care

This Billing and Coding Article provides billing and coding guidance for Local
Coverage Determination (LCD) L35049 Monitored Anesthesia Care. Please refer to
the LCD for reasonable and necessary requirements.  
  
**Coding Guidance  
  
Notice:** It is not appropriate to bill Medicare for services that are not
covered (as described by the entire LCD) as if they are covered. When billing
for non-covered services, use the appropriate modifier.

Anesthesia procedures listed in the "CPT/HCPCS Codes" section of this article
are examples of those that are usually provided by the attending surgeon and
are included in the global fee and are not separately billable. In certain
instances, however, MAC provided by anesthesia personnel may be necessary for
these procedures if the patient has one or more of the conditions or
situations found in the "ICD-10-CM Codes That Support Medical Necessity"
section of this article. The use of anesthesia modifiers, when the CPT code is
not fully descriptive, is **required** as follows:

  * **G8 anesthesia modifier** - used to indicate certain deep, complex, complicated or markedly invasive surgical procedures. This modifier is to be applied to the following anesthesia codes only: 00100, 00300, 00400, 00160, 00532 and 00920.
  * **G9 anesthesia modifier** - represents "a history of severe cardiopulmonary disease" and should be utilized whenever the proceduralist feels the need for MAC due to a history of advanced cardiopulmonary disease. The documentation of this clinical decision-making process and the need for additional monitoring must be clearly documented in the medical record.
  * Anesthesia codes utilized to indicate the clinical condition of the patient receiving MAC: **P1** - healthy individual with minimal anesthesia risk, **P2** - mild systemic disease, **P3** - severe systemic disease with intermittent threat of morbidity or mortality, **P4** - severe systemic illness with ongoing threat of morbidity or mortality, **P5** - premorbid condition with high risk of demise unless procedural intervention is performed.

Special conditions or criteria must be supported by documentation in the
medical record.

Conditions listed under the "Diagnoses that Support Medical Necessity" section
of this article, if matched with anesthesia procedures in the "CPT/HCPCS
Codes" section of the article, could support the need for MAC. Other disease
states can also be considered if medical justification is demonstrated.

  
**Diagnoses that Support Medical Necessity**  
  
Additional diagnoses that do not have a fully descriptive ICD-10-CM code are
listed below. By using the diagnosis code(s) listed, the medical records must
reflect the conditions as described.

  * For combative patients, use ICD-10-CM code F91.9.
  * For patients with low pain thresholds or who suffer severe pain, use ICD-10-CM code G97.81.
  * For intraoperative expansion of procedure, use ICD-10-CM code T81.9XXA.
  * For any condition in a pediatric patient, Medicare eligible and younger than 18 years of age, use ICD-10-CM code T88.8XXA.
  * For patients with mental retardation (patients who are uncooperative due to a lack of understanding caused by their mental disability), use ICD-10-CM code F79.

If MAC is used for these reasons, clinical records must be available upon
request that justify the need for MAC.

**Documentation Requirements**

  1. All documentation must be maintained in the patient's medical record and made available to the contractor upon request.
  2. Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.
  3. The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed.