CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Medical Coverage Policy Anesthesia Services (former title: Monitored Anesthesia Care (MAC))

Defines coverage and reimbursement policy for monitored anesthesia care (MAC), anesthesia codes 00100-01999, and moderate (conscious) sedation CPT codes (99151-99157) for BlueCHiP for Medicare and Commercial Products. Addresses when MAC and moderate sedation are covered and whether separately reimbursed; prior authorization and benefit variability noted.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyMedical Coverage Policy Anesthesia Services (former title: Monitored Anesthesia Care (MAC))

Policy CodePolicy N/A

Change TypeClarified

Effective DateJan 1, 2017

Next Review Date

Key ActionPrior authorization review is not required for anesthesia services under this policy; verify member-specific benefits and report CPT codes per the policy when seeking separate reimbursement.

SourceLink

POLICY UPDATE CHANGES

Policy formerly titled Monitored Anesthesia Care (MAC); content organizes coverage for MAC and moderate sedation and reimbursement rules.

00100-01999Anesthesia CPT range covered

3Moderate sedation codes reimbursable by 2nd provider

3Moderate sedation codes not reimbursed by same provider

Coverage Summary

This policy defines coverage and reimbursement for Monitored Anesthesia Care (MAC) and related moderate (conscious) sedation services for BlueCHiP for Medicare and Commercial Products. Monitored Anesthesia Care (MAC) is defined as a specific anesthesia service for diagnostic or therapeutic procedures that includes a pre-procedure visit, intra-procedure care, and post-procedure anesthesia management, may include varying levels of sedation, and requires qualified personnel prepared to convert to general anesthesia if necessary. Effective date: 01/01/2017; Last review: 02/20/2018.

Key Quick Facts

Anesthesia CPT range (Monitored Anesthesia Care)00100-01999

Moderate sedation codes reimbursable by second provider (count)3

Moderate sedation codes not separately reimbursed when performed by same provider (count)3

Prior authorizationPrior authorization review is not required for anesthesia services under this policy.

Coverage / Reimbursement Criteria

Monitored Anesthesia Care (MAC) Coverage

Policy statements for MAC and moderate sedation reimbursement

ALL of the following

Monitored anesthesia care (MAC) CPT codes 00100-01999 are covered and separately reimbursed.

Moderate (Conscious) Sedation - Separate Reimbursement by Second Provider

Covered and separately reimbursed when provided by a provider other than the proceduralist

ALL of the following

Applicable CPT codes
- 99155
- 99156
- 99157
Applicable specialties
- Emergency medicine (specialty code 093)
- Critical Care (specialty code 079)
- Anesthesia specialties
- Another physician who is credentialed/qualified to perform these services

Moderate (Conscious) Sedation - Not Separately Reimbursed when Performed by Proceduralist

Moderate sedation performed by the same provider as the diagnostic/therapeutic service

ALL of the following

Not separately reimbursed CPT codes
- 99152
- 99151
- 99153
- Moderate sedation services provided by the same physician or other qualified health care professional performing a gastrointestinal endoscopic service that the sedation supports, requiring the presence of an independent trained observer to assist in monitoring; initial 15 minutes; patient age 5 years or older (additional time may be reported with 99153 as appropriate)

Coding

Covered Anesthesia CPT rangeCPTCovered

00100-01999

Anesthesia codes (Monitored Anesthesia Care MAC) - covered and separately reimbursed

Moderate sedation codes - separately reimbursed when performed by second providerCPTCovered

99155	Moderate sedation services provided by a physician or other qualified health care professional other than the physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports; initial 15 minutes of intraservice time; patient younger than 5 years of age
99156	Moderate sedation services provided by a physician or other qualified health care professional other than the physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports; initial 15 minutes of intraservice time; patient age 5 years or older
99157	Moderate sedation services provided by a physician or other qualified health care professional other than the physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports; each additional 15 minutes intraservice time (List separately in addition to code for primary service)

Moderate sedation codes - not separately reimbursed when performed by same providerCPTNot Covered

99152	Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer; initial 15 minutes of intraservice time; patient age 5 years or older
99151	Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer; initial 15 minutes of intraservice time; patient younger than 5 years of age
99153	Each additional 15 minutes intraservice time when performed by the same provider (List separately in addition to code for primary service); used for additional intra-service time for moderate sedation provided by the same provider

Provider Actions & Billing Rules

Prior Authorization

Prior authorization not required

Prior authorization review is not required for anesthesia services under this policy.

Documentation Required

Benefit verification

Verify member-specific benefits and eligibility in the applicable Benefit Booklet, Evidence of Coverage, or Subscriber Agreement as benefits may vary between groups/contracts.

Verify member-specific benefits and eligibility in Benefit Booklet/Evidence of Coverage/Subscriber Agreement

Billing Rule

Separate reimbursement rules for moderate sedation

Report CPT codes 99155, 99156, 99157 for moderate sedation when performed by a second provider to be eligible for separate reimbursement; do not report 99151, 99152, 99153 for separate reimbursement when performed by the same provider.

Affected CPT codes: 99155, 99156, 99157, 99151, 99152, 99153
Report 99155-99157 when performed by a second provider; do not report 99151-99153 for separate reimbursement when performed by the same provider.

Documentation Required

Credentialing/specialty requirement for second provider

When seeking separate reimbursement as a second provider, the second provider must be in an applicable specialty (Emergency medicine, Critical Care, Anesthesia specialties) or be credentialed/qualified to perform these services.

Emergency medicine
Critical Care
Anesthesia specialties
Or a physician who is credentialed/qualified to perform these services

Background & Clinical Context

Background: The American Society of Anesthesiologists (ASA) defines MAC as an anesthesia service for diagnostic or therapeutic procedures where indications include the nature of the procedure, the patient’s clinical condition, and potential need to convert to a regional or general anesthetic. MAC “includes all aspects of anesthesia care” such as a pre-procedure visit, intra-procedure monitoring and management, and post-procedure anesthesia care.

The ASA levels of sedation/analgesia are: Minimal sedation (anxiolysis) — responds normally to verbal commands; Moderate sedation/analgesia (conscious sedation) — purposeful response to verbal commands with adequate ventilation and cardiovascular function; Deep sedation/analgesia — not easily arousable, may require assistance maintaining airway and ventilation; and General anesthesia — unarousable even to painful stimulation, often requiring airway support and positive-pressure ventilation.

Scope of MAC: MAC may include varying levels of sedation, analgesia, and anxiolysis as needed for outpatient procedures (e.g., endoscopy, colonoscopy, bronchoscopy, interventional procedures). Sedation in outpatient settings should be administered by qualified and appropriately trained personnel; providers of MAC must be prepared and qualified to convert to general anesthesia if necessary.

Personnel and risks: ASA standards call for MAC to be provided by qualified anesthesia personnel in addition to the proceduralist, present continuously to monitor and provide care. Because sedation is a continuum, practitioners must be able to rescue patients who progress to deeper levels of sedation than intended. Common moderate sedation regimens include combinations of benzodiazepines and opioids (with available reversal agents). Propofol is increasingly used for procedural sedation due to rapid onset and recovery but raises safety concerns when administered by non-anesthesiologists because it can induce general anesthesia and has no pharmacologic antagonist; ASA guidelines stress that personnel must be prepared to respond to loss of airway protection or deeper levels of sedation.

Evidence and references: The policy cites ASA position statements and practice standards on monitored anesthesia care, distinguishing MAC from moderate sedation, the continuum of depth of sedation, and qualifications for anesthesia providers in office-based settings. Peer-reviewed evidence referenced includes systematic reviews and studies such as the AGA Institute review of endoscopic sedation, Cochrane review of propofol for colonoscopy, and multiple Gastrointest Endosc and Clin Gastroenterol Hepatol reports on sedation-related adverse events and anesthesiologist-administered sedation outcomes.

Definition

Monitored Anesthesia Care (MAC)A specific anesthesia service for diagnostic or therapeutic procedures including pre-procedure visit, intra-procedure care, and post-procedure anesthesia management; may include varying levels of sedation and requires qualified personnel prepared to convert to general anesthesia if necessary.

OpenPayer

Medical Coverage Policy Anesthesia Services (former title: Monitored Anesthesia Care (MAC))

Coverage Summary

Coverage / Reimbursement Criteria

Coding

Provider Actions & Billing Rules

Background & Clinical Context

Revision History