CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Monitored Anesthesia Care (MAC) for GI endoscopic procedures

Policy governs coverage of monitored anesthesia care (MAC) for outpatient gastrointestinal endoscopic diagnostic or therapeutic procedures (upper, lower, combined) for BlueCHiP for Medicare and Commercial products, including indications, documentation and applicable CPT anesthesia codes.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyMonitored Anesthesia Care (MAC) for GI endoscopic procedures

Policy CodePolicy N/A

Change Typeclarified

Effective DateJul 1, 2018

Next Review Date

Key ActionDocument medical necessity in the member's medical record; BCBSRI may audit and deny or retract payment if documentation is not produced.

SourceLink

POLICY UPDATE CHANGES

Policy states prior authorization is not required and clarifies covered indications for MAC for GI endoscopy.

5+Listed clinical high-risk indications

5Covered CPT codes

Coverage / Indications

Monitored Anesthesia Care (MAC) for gastrointestinal endoscopic procedures is covered for elective upper, lower, and combined endoscopy for members who have a higher risk for sedation-related complications when documentation supports medical necessity. Use of MAC for average-risk patients undergoing standard upper and lower GI endoscopy is not appropriate.

Prior Authorization & Documentation

Prior Authorization

Prior authorization not required

Prior authorization is not required for monitored anesthesia care (MAC) for gastrointestinal endoscopic procedures.

Documentation Required

Document medical necessity

Member medical records must document that MAC services are medically necessary for the care provided. BCBSRI may audit the services and request documentation; failure to produce requested information may result in denial or retraction of payment.

Denial Risk

Denial risk for routine MAC in average-risk patients

Routine use of MAC for average-risk patients undergoing standard upper and lower GI endoscopy is not appropriate and may not be covered, creating a risk of denial when MAC is used routinely for average-risk patients.

Documentation Required

Provider qualifications and readiness

The provider of MAC must be prepared and qualified to convert to general anesthesia when necessary and to intervene to rescue the airway and support vital functions; this capability is a prerequisite to providing MAC.

Not Appropriate / Not Covered

Situations where routine MAC is not appropriate

Routine use of MAC for average-risk patients undergoing standard upper and lower GI endoscopy is not appropriate.

MAC is not appropriate routinely for average-risk GI endoscopy patients: guideline statements from the American Society for Gastrointestinal Endoscopy (2008) note the routine use of MAC for average-risk patients undergoing standard upper and lower GI endoscopy is not appropriate, consistent with positions from the American Society of Anesthesiologists.

Relevant CPT Anesthesia Codes

Covered CPT (Anesthesia for GI endoscopic procedures)CPTCovered

00732	Anesthesia for upper gastrointestinal endoscopic procedures, endoscope introduced proximal to duodenum; endoscopic retrograde cholangiopancreatography (ERCP)
00731	Anesthesia for upper gastrointestinal endoscopic procedures, endoscope introduced proximal to duodenum; not otherwise specified
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

Covered CPT (Anesthesia for GI endoscopic procedures)CPTCovered

00732	Anesthesia for upper gastrointestinal endoscopic procedures, endoscope introduced proximal to duodenum; endoscopic retrograde cholangiopancreatography (ERCP)
00731	Anesthesia for upper gastrointestinal endoscopic procedures, endoscope introduced proximal to duodenum; not otherwise specified
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

Background & Evidence

Monitored Anesthesia Care (MAC) involves drug-induced depression of consciousness during which the patient may respond purposefully to verbal commands and is monitored by a practitioner qualified to administer anesthesia. MAC typically maintains cardiovascular function with spontaneous ventilation but includes an assessment and management role pre-, intra-, and post-procedure. The provider of MAC must be prepared and qualified to convert to general anesthesia and to intervene to protect the airway and support vital functions as necessary. ASA and ASGE guidance indicate MAC is not routinely appropriate for average-risk GI endoscopy patients but is appropriate for higher-risk individuals.

Guideline references: American Society of Anesthesiologists Position on Monitored Anesthesia Care (2013); American Society for Gastrointestinal Endoscopy, Sedation and Anesthesia in GI Endoscopy (2008) and related ASGE/ASA statements.

Prior Authorization

Prior authorization requirements for MAC for GI endoscopy

Prior authorization is not required.

Definitions

Monitored Anesthesia Care (MAC): Anesthesia care involving drug-induced depression of consciousness during which patients may respond purposefully to verbal commands and are monitored by a practitioner qualified to administer anesthesia; provider must be prepared to convert to general anesthesia as needed.

ASA Physical Status P2: A patient with mild systemic disease.