Article - Billing and Coding: Monitored Anesthesia Care (A57361)

CMS National Coverage PolicySocial Security Act (Title XVIII) Standard References:Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior period.Article TextThis 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 GuidanceNotice: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, isrequiredas 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 NecessityAdditional 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 RequirementsAll documentation must be maintained in the patient's medical record and made available to the contractor upon request.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.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.