CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

2021 Monitored Anesthesia Care For Gastrointestinal Endoscopic Procedures

Defines coverage policy for monitored anesthesia care (MAC) for outpatient gastrointestinal endoscopic diagnostic and therapeutic procedures for Medicare Advantage and Commercial products, including indications, documentation and covered CPT anesthesia codes. Prior authorization is not required.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

Policy2021 Monitored Anesthesia Care For Gastrointestinal Endoscopic Procedures

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJul 1, 2018

Next Review Date

Key ActionProvider must document in the medical record that MAC is medically necessary for the procedure and the member meets high-risk criteria; documentation must be available to BCBSRI upon request.

SourceLink

POLICY UPDATE CHANGES

No material changes: has_material_change=false

5Covered CPT codes

MultipleHigh-risk clinical indications listed

Not requiredPrior Authorization

Coverage Summary

This policy defines coverage for Monitored Anesthesia Care (MAC) for outpatient gastrointestinal endoscopic diagnostic and therapeutic procedures for Medicare Advantage and Commercial products. MAC is covered with criteria for members who meet specified high-risk indications; covered CPT anesthesia codes include 00731, 00732, 00811, 00812, and 00813. For Medicare Advantage Plans and Commercial Products, prior authorization is not required. Effective date: 07/01/2018; Policy last updated (last review): 11/17/2021.

Coding

Covered CPT anesthesia codes (Medicare Advantage and Commercial Products)CPTCovered

00731	Anesthesia for upper gastrointestinal endoscopic procedures, endoscope introduced proximal to duodenum; not otherwise specified
00732	Anesthesia for upper gastrointestinal endoscopic procedures, endoscope introduced proximal to duodenum; endoscopic retrograde cholangiopancreatography (ERCP)
00811	Anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum; not otherwise specified
00812	Anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum; screening colonoscopy
00813	Anesthesia for combined upper and lower gastrointestinal endoscopic procedures, endoscope introduced both proximal to and distal to the duodenum

Provider Actions

Documentation Required

Document medical necessity

Provider must document in the medical record that MAC is medically necessary for the procedure and the member meets high-risk criteria; documentation must be available to BCBSRI upon request.

Billing Rule

Use listed anesthesia CPT codes

Report the appropriate CPT anesthesia code for the endoscopic procedure performed.

00731
00732
00811
00812
00813

Prior Authorization

Prior authorization not required

For Medicare Advantage Plans and Commercial Products, prior authorization is not required for MAC for GI endoscopic procedures.

Denial Risk

Denial or retraction risk for insufficient documentation

Failure to produce the requested documentation may result in denial or retraction of payment.

Background

Monitored Anesthesia Care (MAC) is intended for patients at higher risk for sedation-related complications or when procedures may require deeper levels of sedation or conversion to general anesthesia (for example prolonged or therapeutic procedures, ERCP, stent placement, or complex therapeutic interventions). The provider must be prepared and qualified to convert to general anesthesia if needed and to manage airway and physiologic derangements during the procedure.

Routine use of MAC for average-risk patients undergoing standard upper or lower GI endoscopy is not appropriate; clinicians should consider MAC based on the nature of the procedure, the patient’s clinical condition, and the potential need to convert to general or regional anesthetic.

Monitored Anesthesia Care (MAC): Anesthesia care involving drug-induced depression of consciousness during which the patient may respond purposefully to verbal commands (with or without light tactile stimulation), requiring monitoring by a practitioner qualified to administer anesthesia; the provider must be prepared and qualified to convert to general anesthesia when necessary.

ASA Physical Status Modifiers: The P1–P6 scale describing pre-anesthesia medical comorbidities (P2 or greater indicates mild to severe systemic disease) used to characterize increased risk for complications.

Evidence and guideline references include American Society of Anesthesiologists (ASA) position statements and guidance distinguishing MAC from moderate sedation and describing the provider qualifications and responsibilities for MAC, as well as GI society guidelines (American Society for Gastrointestinal Endoscopy and others) that note routine MAC for average-risk patients is not appropriate and provide recommendations on patient screening to determine appropriate sedation level.