CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Monitored Anesthesia Care (MAC) for Gastrointestinal Endoscopic Procedures

Defines coverage for monitored anesthesia care (MAC) for outpatient gastrointestinal endoscopic diagnostic and therapeutic procedures (upper and lower endoscopy) for Medicare Advantage and commercial products, including clinical circumstances where MAC is considered appropriate, documentation/audit rights, and billing code guidance.

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 Date

Next Review Date

Key ActionDocument medical necessity and risk factors in the member's medical record and make documentation available for BCBSRI audit; failure to produce may result in denial or retraction of payment.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes; policy content remains current.

5Primary covered CPT codes listed

12Common clinical indications enumerated

0Prior authorization required

Coverage Summary

This policy defines coverage for Monitored Anesthesia Care (MAC) for outpatient gastrointestinal endoscopic diagnostic and therapeutic procedures (upper and lower endoscopy) for Medicare Advantage and commercial products. The policy stance is covered_with_criteria, specifying that MAC is a covered service for elective upper and lower endoscopy for members with a higher risk for sedation-related complications and that documentation of medical necessity must be maintained and made available for audit.

Key facts

Policy subjectMonitored Anesthesia Care (MAC) for Gastrointestinal Endoscopic Procedures

StatusCURRENT

PayerBlue Cross Blue Shield - Rhode Island (BCBSRI)

Effective date

Scope summaryDefines coverage for monitored anesthesia care (MAC) for outpatient gastrointestinal endoscopic diagnostic and therapeutic procedures (upper and lower endoscopy) for Medicare Advantage and commercial products, including clinical circumstances where MAC is considered appropriate, documentation/audit rights, and billing code guidance.

Morbid obesity threshold (example)BMI > 40 kg/m2

When MAC is Medically Appropriate

Coverage Criteria — When MAC is considered appropriate

MAC for GI endoscopy is covered for elective upper and lower endoscopy for members with a higher risk for sedation-related complications; use when ANY of the following apply:

ANY of the following

Member is under 18 years of age
Member is over 70 years of age
Member is pregnant
Member is acutely agitated and/or uncooperative
Increased risk for complications due to severe comorbidity (ASA class III, IV, or V)
Refer to ASA Physical Status Classification
Increased risk for airway obstruction due to anatomic variation — ANY of
- History of stridor
- Dysmorphic facial features
- Oral abnormalities (e.g. macroglossia)
- Neck abnormalities (e.g. neck mass)
- Jaw abnormalities (e.g. micrognathia)
Prolonged or therapeutic GI procedures requiring deep sedation — ANY of
- Endoscopy in members with adhesions after abdominal surgery
- Endoscopic retrograde cholangiopancreatography (ERCP)
- Stent placement in the upper gastrointestinal tract
- Complex therapeutic procedures, such as plication of the cardioesophageal junction
Member has one of the following risk/history factors — ANY of
- History of adverse reaction to sedation
- History of inadequate response to sedation
- History or anticipated intolerance to standard sedatives (e.g. chronic opioid use, chronic benzodiazepine use)
- Documented sleep apnea
- Morbid obesity (e.g. BMI > 40kg/m2)BMI > 40 kg/m2
- Active medical problems related to drug or alcohol abuse
Anticipated prolonged procedure where therapeutic intervention may be involved

Operational / Provider qualifications

Conditions governing who may provide MAC and facility requirements:

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 anesthesia
The person administering anesthesia shall not function in any other capacity during the surgical procedure
Qualified anesthesia provider must be prepared to manage all levels of sedation up to and including general anesthesia and respond to airway and hemodynamic changes

Billing Codes and Modifiers

Covered CPT codes for MAC for GI endoscopy (Medicare Advantage and Commercial)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

Physical Status Modifiers (report as applicable)Modifier

P1	ASA Class I: A normal, healthy individual
P2	ASA Class II: An individual with mild systemic disease
P3	ASA Class III: An individual with severe systemic disease
P4	ASA Class IV: An individual with severe systemic disease that is a constant threat to life
P5	ASA Class V: A moribund individual who is not expected to survive without the operation
P6	ASA Class VI: A declared brain-dead individual whose organs are being harvested

Billing Rule

Report appropriate CPT and modifiers

Providers should report services using current procedure, revenue, diagnosis codes, and applicable modifiers; include Physical Status Modifiers P1–P6 based on ASA classification as appropriate.

00731
00732
00811
00812
00813
P1–P6

Background, Evidence, and Definitions

Background: The policy addresses the use of monitored anesthesia care (MAC) versus moderate sedation for outpatient GI endoscopy and lists clinical circumstances where MAC is appropriate, including age extremes, pregnancy, agitation or uncooperativeness, severe comorbidity (ASA class III–V), anatomic airway risk factors, prolonged or therapeutic/complex procedures (e.g., ERCP, stent placement, adhesions-related procedures), and patient risk/history factors such as prior adverse reaction or inadequate response to sedation, chronic opioid/benzodiazepine use, documented sleep apnea, morbid obesity (e.g., BMI > 40 kg/m2), substance-related problems, inability to follow commands, or movement disorders.

The policy references American Society of Anesthesiologists (ASA) statements that distinguish MAC from moderate sedation and outline expectations that a qualified anesthesia provider administer MAC, perform pre-, intra-, and post-procedural anesthesia care, be prepared to manage all levels of sedation up to and including general anesthesia, respond to airway and hemodynamic changes, and not function in any other capacity during the procedure.

Reference	Summary
ASA statement update
ASA updated statements distinguishing MAC from moderate sedation (October 2023) and outlining expectations that MAC is an anesthesia service provided by a qualified anesthesia provider with pre-, intra-, and post-procedural responsibilities

Definitions

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

ASA Physical Status Modifiers P1–P6: Modifiers corresponding to ASA classification I–VI used to indicate patient's preoperative physical status (P1: normal healthy; P2: mild systemic disease; P3: severe systemic disease; P4: severe systemic disease that is a constant threat to life; P5: moribund not expected to survive without operation; P6: declared brain-dead, organs being harvested).