CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Monitored Anesthesia Care (MAC) for gastrointestinal endoscopic procedures

Defines coverage policy for monitored anesthesia care (MAC) when provided for outpatient gastrointestinal endoscopic diagnostic or therapeutic procedures, including indications, provider qualifications, and applicable CPT codes for Medicare Advantage and commercial products.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyMonitored Anesthesia Care (MAC) for gastrointestinal endoscopic procedures

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJul 1, 2018

Next Review DateN/A

Key ActionMember's medical records must document that MAC services are medically necessary for the care provided; BCBSRI may audit and request documentation and may deny or retract payment if documentation is not produced.

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes in this policy update.

5Key patient risk categories listed

5Covered CPT codes specified

1Provider types required

Coverage Summary

Defines coverage policy for Monitored Anesthesia Care (MAC) when provided for outpatient gastrointestinal endoscopic diagnostic or therapeutic procedures. Coverage stance: covered_with_criteria. Effective date: 2018-07-01. Policy last reviewed: 2024-02-21. Applicable to Medicare Advantage and commercial products and references specific CPT codes for MAC for GI endoscopy.

Medical Necessity / Coverage Criteria

Coverage / Medical Necessity Criteria

MAC for gastrointestinal endoscopic procedures is covered when the member meets ANY of the following clinical risk or procedure-related criteria:

ANY of the following

Member is under 18 years of age
Member is over 70 years of age
Member is pregnant
Increased risk for complications due to severe comorbidity (ASA class III, IV, or V)
Refer to ASA Physical Status Classification
Member is acutely agitated and/or uncooperative
Increased risk for airway obstruction due to anatomic variation (history of stridor; dysmorphic facial features; neck abnormalities such as neck mass; oral abnormalities such as macroglossia; jaw abnormalities such as micrognathia)
Endoscopy in members with adhesions after abdominal surgery
Prolonged or therapeutic gastrointestinal endoscopy procedures requiring sedation, e.g., endoscopic retrograde cholangiopancreatography (ERCP), complex therapeutic procedures (plication of the cardioesophageal junction), or stent placement in the upper gastrointestinal tract
History of inadequate response to sedation
History of adverse reaction to sedation
History or anticipated intolerance to standard sedatives (including chronic opioid use, chronic benzodiazepine use)
Morbid obesity (BMI > 40 kg/m2)> 40 kg/m2
Documented sleep apnea
Active medical problems related to drug or alcohol abuse
Spasticity or movement disorder complicating the procedure
Inability to follow simple commands (cognitive dysfunction, intoxication, or psychological impairment)

Provider and Setting Requirements

MAC must be provided by qualified personnel in appropriate facility:

ALL of the following

MAC should be administered in a licensed facility administering all types of anesthesia, other than general anesthesia
An anesthesiologist, certified registered nurse anesthetist, or a physician shall administer MAC
The person administering anesthesia shall not function in any other capacity during the surgical/procedural procedure

CPT and Modifiers

Covered CPT codes for MAC - GI endoscopyCPTCovered

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

Suggested / Required ModifiersModifier

P1-P6

Physical Status Modifiers P1 through P6 based on ASA Classification I through VI

Providers should report all services using current procedure, revenue, and diagnosis codes and applicable modifiers. This includes reporting the covered MAC CPT codes for GI endoscopy (e.g., 00731, 00732, 00811, 00812, 00813) and applicable ASA Physical Status modifiers P1–P6. Member medical records must document medical necessity and may be audited; failure to produce documentation may result in denial or retraction of payment.

Provider Actions & Documentation Requirements

Documentation Required

Medical record documentation of medical necessity

Member's medical records must document that MAC services are medically necessary for the care provided; BCBSRI may audit and request documentation and may deny or retract payment if documentation is not produced.

BCBSRI may audit and deny or retract payment if documentation not produced.

Billing Rule

Report services and modifiers

Providers should report all services using current procedure, revenue, diagnosis codes, and applicable modifiers (including ASA physical status modifiers P1–P6).

00731
00732
00811
00812
00813
P1-P6

Background & Evidence

Policy addresses appropriateness of MAC versus moderate sedation for outpatient GI endoscopy, listing clinical and procedure-related circumstances where MAC is appropriate (e.g., age extremes, pregnancy, severe comorbidity/ASA class III–V, anatomic airway risk, prolonged/therapeutic procedures, morbid obesity, documented sleep apnea, history of inadequate response or adverse reaction to sedation, substance use, movement disorders, inability to follow commands). The policy emphasizes distinctions between MAC and moderate sedation per ASA statements and details provider qualifications and setting requirements: MAC must be provided by a qualified anesthesia provider (anesthesiologist, CRNA, or physician) in a licensed facility and the anesthesia provider must not function in any other capacity during the procedure. The policy references ASA position statements, guidance on MAC vs moderate sedation, and multiple clinical guidelines and literature supporting these recommendations.

ASA Position / Statements: Cites American Society of Anesthesiologists positions distinguishing MAC from moderate sedation and describing MAC as a specific anesthesia service (references include ASA Position on Monitored Anesthesia Care, ASA Continuum of Depth of Sedation, and ASA statements updated/amended in 2018, 2019, and 2023).

Definitions

Monitored Anesthesia Care (MAC)Anesthesia care involving drug-induced depression of consciousness in which the patient may respond purposefully to verbal commands and requires monitoring by a practitioner qualified to administer anesthesia; may include varying levels of sedation up to general anesthesia and includes pre-, intra-, and post-procedure care by a qualified anesthesia provider.

ASA Physical Status Modifiers P1-P6Modifiers indicating ASA Classification I through VI for patient physical status.