CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Monitored Anesthesia Care (MAC) for gastrointestinal endoscopic procedures

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 ActionDocument in the member's medical record that MAC is medically necessary and maintain documentation for BCBSRI audit; failure to produce documentation may result in denial or retraction of payment.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this update.

5CPT codes listed

15Clinical indications/examples listed

Coverage Summary

Defines coverage and documentation requirements for monitored anesthesia care (MAC) for outpatient gastrointestinal endoscopic diagnostic or therapeutic procedures (upper, lower, combined) for Blue Cross Blue Shield of Rhode Island Commercial and BlueCHiP for Medicare members; prior authorization is not required for these products and covered CPT codes include 00731, 00732, 00811, 00812, and 00813.

Medical Necessity Criteria

Medical Necessity for MAC (coverage criteria)

Monitored anesthesia care for GI endoscopic procedures is covered when members have a higher risk for sedation-related complications; MAC is considered appropriate in the following circumstances:

Any of the following indicate appropriateness

Member is under 18 years of age
Member is over 70 years of age
Member is pregnant
Increased risk for airway obstruction due to anatomic variation
Increased risk for complications due to severe co-morbidity corresponding to ASA Physical Status Modifier of P2 or greater
History of stridor
Oral abnormalities (e.g., macroglossia)
Dysmorphic facial features
Neck abnormalities (e.g., neck mass)
Jaw abnormalities (e.g., micrognathia)
History of adverse reaction to sedation
History of inadequate response to sedation
Morbid obesity (e.g., BMI > 40)BMI > 40
Obstructive sleep apnea
Active alcohol or substance use disorder

Documentation requirement

Coverage conditional on documentation

ALL of the following

Member medical records must document that services are medically necessary for the care provided
Documentation must be available to BCBSRI upon request
Operative denial risk / audit clause: Failure to produce requested information may result in denial or retraction of payment

Coding

Covered CPT codes for anesthesia for GI endoscopic proceduresCPTCovered

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 member's medical record that monitored anesthesia care (MAC) is medically necessary for the care provided and maintain that documentation for BCBSRI audit. All documentation must be available to BCBSRI upon request; failure to produce requested information may result in denial or retraction of payment.

BCBSRI may audit services regardless of provider participation status.

Prior Authorization

Prior authorization not required

Prior authorization is not required for BlueCHiP for Medicare and Commercial Products for monitored anesthesia care for gastrointestinal endoscopic procedures.

Background & Definitions

Monitored Anesthesia Care (MAC) is anesthesia care involving a drug-induced depression of consciousness in which the patient may respond purposefully to verbal commands and is monitored by a practitioner qualified to administer anesthesia; MAC includes pre-procedure assessment, intra-procedure care, and post-procedure anesthesia management, and the provider must be prepared and qualified to convert to general anesthesia when necessary. MAC is distinct from moderate sedation because it requires readiness and capability to intervene for airway or other anesthesia-related complications. Guidance from the American Society for Gastrointestinal Endoscopy and the American Society of Anesthesiologists states that the routine use of MAC for average-risk patients undergoing standard upper and lower GI endoscopy is not appropriate.

Definitions

ASA Physical Status Modifiers