CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

2018 Anesthesia Services_1_0

Policy governs coverage and reimbursement for monitored anesthesia care (MAC) and moderate (conscious) sedation for diagnostic and therapeutic procedures in outpatient settings for BlueCHiP for Medicare and Commercial products. It specifies which anesthesia and sedation CPT ranges/codes are covered and whether services are separately reimbursed.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

Policy2018 Anesthesia Services_1_0

Policy CodePolicy N/A

Change TypeClarified

Effective DateJan 1, 2017

Next Review Date

Key ActionProviders should document that monitored anesthesia care meets ASA definitions and include details of pre/intra/post-procedure anesthesia management, and personnel qualifications when billing MAC (anesthesia codes 00100-01999).

SourceLink

POLICY UPDATE CHANGES

Policy affirms MAC (anesthesia codes 00100-01999) is covered and separately reimbursed and clarifies reimbursement differences for moderate sedation codes based on provider performing the service.

00100-01999MAC coverage

99155-99157Moderate sedation (2nd provider)

99151-99153,G0500Moderate sedation (same provider)

Coverage Summary

This policy governs coverage and reimbursement for anesthesia services for diagnostic and therapeutic procedures performed in outpatient settings, specifically addressing Monitored Anesthesia Care (MAC) and moderate (conscious) sedation. Monitored Anesthesia Care (anesthesia CPT codes 00100-01999) is covered and separately reimbursed. Moderate sedation has a mixed coverage stance: when provided by a provider other than the proceduralist (CPT 99155-99157) it is covered and separately reimbursed, whereas moderate sedation provided by the same clinician performing the diagnostic or therapeutic service (CPT 99151-99153 and G0500) is covered but not separately reimbursed.

Coverage / Medical Necessity Criteria

Monitored Anesthesia Care (MAC) Coverage

Covered when provided for diagnostic or therapeutic outpatient procedures:

ALL of the following

Service is monitored anesthesia care (MAC) as defined by ASA, including pre-procedure, intra-procedure and post-procedure anesthesia management
Performed in outpatient setting

Moderate (Conscious) Sedation Coverage - Provider other than proceduralist

Covered and separately reimbursed when ALL of the following are met:

ALL of the following

Moderate sedation is rendered by a provider other than the provider performing the diagnostic or therapeutic service
Applies to CPT codes 99155 - 99157 (initial 15 minutes and additional 15-minute increments)

Moderate (Conscious) Sedation Coverage - Same provider / proceduralist

Covered but not separately reimbursed when ALL of the following are met:

ALL of the following

Moderate sedation is rendered by the same provider who is performing the diagnostic or therapeutic service
Applies to CPT codes 99151 - 99153 and G0500
When performed by same provider, sedation is covered but payment is bundled (not separately reimbursed)

CPT / HCPCS Codes and Coverage Status

Monitored Anesthesia Care (covered, separately reimbursed)CPTCovered

00100-01999

Anesthesia codes (Monitored Anesthesia Care)

Moderate sedation by second provider (covered, separately reimbursed)CPTCovered

99155	Moderate sedation services by other than the procedural provider; initial 15 minutes; patient younger than 5 years
99156	Moderate sedation services by other than the procedural provider; initial 15 minutes; patient age 5 years or older
99157	Moderate sedation each additional 15 minutes intraservice time (List separately)

Moderate sedation by same provider (covered, not separately reimbursed)CPT|HCPCSNot Covered

99151	Moderate sedation by same provider; initial 15 minutes; patient younger than 5 years
99152	Moderate sedation by same provider; initial 15 minutes; patient age 5 years or older
99153	Moderate sedation each additional 15 minutes (for same provider)
G0500	Moderate sedation by same provider for GI endoscopic service; initial 15 minutes; patient age 5 years or older

Provider Actions and Billing Rules

Documentation Required

Document MAC indications and anesthesia personnel

Providers should document that monitored anesthesia care meets ASA definitions and include details of pre/intra/post-procedure anesthesia management, and personnel qualifications when billing MAC (anesthesia codes 00100-01999).

Affected codes: 00100-01999

Billing Rule

Separate reimbursement for MAC and for moderate sedation by second provider

Report anesthesia codes (00100-01999) for MAC; moderate sedation codes 99155-99157 are eligible for separate reimbursement when performed by a second provider in facility settings and a separate physician is dedicated to sedation.

Affected codes: 00100-01999, 99155-99157
Note: Separate reimbursement for 99155-99157 applies when performed in a facility setting by a second provider and when a separate physician is dedicated to sedation (applies to certain specialties and credentialed/qualified physicians).

Billing Rule

Bundling rule for moderate sedation by same provider

Moderate sedation codes 99151-99153 and G0500 are covered but not separately reimbursed when provided by the same clinician performing the diagnostic or therapeutic service.

Affected codes: 99151-99153, G0500
Note: These codes are covered but payment is bundled (not separately reimbursed) when performed by the proceduralist.

Background and Definitions

The American Society of Anesthesiologists (ASA) defines Monitored Anesthesia Care (MAC) as a specific anesthesia service for diagnostic or therapeutic procedures that includes pre-procedure visit, intra-procedure care and post-procedure anesthesia management; indications include procedure type, patient clinical condition, and potential need to convert to general or regional anesthetic. MAC may include varying levels of sedation, analgesia, and anxiolysis as necessary, and providers must be prepared and qualified to convert to general anesthesia when indicated.

ASA classifies levels of sedation/analgesia into four tiers: Minimal sedation (anxiolysis), Moderate sedation/analgesia (conscious sedation), Deep sedation/analgesia, and General anesthesia, with progressively greater impairment of responsiveness and ventilatory/cardiovascular function across the continuum.

Because sedation exists on a continuum, practitioners intending to produce a given level of sedation must be able to rescue patients whose sedation becomes deeper than intended. Those administering moderate sedation should be able to rescue patients who enter deep sedation, and those administering deep sedation should be able to rescue patients who enter general anesthesia.

Propofol is increasingly used for procedural sedation due to rapid onset and fast recovery, but it can induce general anesthesia and has no pharmacologic antagonist; ASA guidance emphasizes safety concerns and states personnel must be prepared to respond to deep sedation and loss of airway protection if complications occur during sedation.

Monitored Anesthesia Care (MAC): A specific anesthesia service for a diagnostic or therapeutic procedure that includes pre-procedure visit, intra-procedure care, and post-procedure anesthesia management; indications include the nature of the procedure, the patient's clinical condition, and potential need to convert to general or regional anesthetic.

Revision History

01|01|2017clarified

Policy affirms MAC (anesthesia codes 00100-01999) is covered and separately reimbursed and clarifies reimbursement differences for moderate sedation codes based on provider performing the service. Detail: Monitored anesthesia care (MAC) CPT codes 00100-01999 are covered and separately reimbursed; moderate sedation CPT codes 99155-99157 are covered and separately reimbursed when rendered by a provider other than the provider performing the diagnostic or therapeutic service; CPT codes 99151-99153 (and G0500 for GI endoscopy) are covered but not separately reimbursed when rendered by the same provider performing the diagnostic or therapeutic service. Benefits may vary by contract and prior authorization is not required.

02|20|2018clarifiedLatest

Policy reaffirmation and update of effective/last review dates. Detail: Effective date 01|01|2017 with policy last updated 02|20|2018; prior authorization not required; benefits may vary between groups/contracts and refer to benefit booklet for specifics.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

Policy2018 Anesthesia Services_1_0

Policy CodePolicy N/A

Change TypeClarified

Effective DateJan 1, 2017

Next Review Date

SourceLink

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