Monitored Anesthesia Care for Gastrointestinal Endoscopic Procedures
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This policy governs coverage and coding for monitored anesthesia care (MAC) provided for outpatient gastrointestinal endoscopic diagnostic and therapeutic procedures for members of Blue Cross Blue Shield of Rhode Island.
No material clinical or coverage changes in this revision.
Coverage Criteria
Covered when ALL of the following apply (elective upper and lower endoscopy)
Covered when ALL of the following apply:
From policy statement (coverage overview)
From policy documentation and audit statements
Specific patient or procedure indications
- Age: Member is under 18 years of age OR member is over 70 years of age.
- Physiologic states: Member is pregnant.
- Behavioral: Member is acutely agitated and/or uncooperative.
- ASA class / severe comorbidity: Increased risk for complications due to severe comorbidity (ASA class III, IV, or V).
Refer to ASA Physical Status Classification
Anatomic increased airway obstruction risk
- 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 procedures
- Post-abdominal surgery adhesions: Endoscopy in members with adhesions after abdominal surgery.
- ERCP: Endoscopic retrograde cholangiopancreatography (ERCP).
- Upper GI stent placement: Stent placement in the upper gastrointestinal tract.
- Complex therapeutic procedures (e.g., plication of the cardioesophageal junction).
Other individual risk factors
- Adverse reaction to sedation: History of adverse reaction to sedation.
- Inadequate response to sedation: History of inadequate response to sedation.
- Intolerance to standard sedatives: History or anticipated intolerance to standard sedatives, such as chronic opioid use or chronic benzodiazepine use.
- Documented sleep apnea.
- Morbid obesity (e.g., BMI > 40 kg/m2).> 40 kg/m2
Threshold from coding/thresholds section
- Active substance-related medical problems: Active medical problems related to drug or alcohol abuse.
- Inability to follow commands: Inability to follow simple commands (cognitive dysfunction, intoxication, or psychological impairment).
- Spasticity or movement disorder complicating the procedure.
- Anticipated prolonged therapeutic intervention: Anticipated prolonged procedure where therapeutic intervention may be involved.
Coverage and benefits for anesthesia and surgery services vary by group or contract. Please consult the member's applicable Benefit Booklet, Evidence of Coverage, or Subscriber Agreement to determine whether monitored anesthesia care (MAC) is a covered benefit for that member.
Even when services are medically necessary, they may be excluded from coverage under a member's contract. For member-specific benefit determinations, contact the provider call center and confirm the member's subscriber agreement or employer agreement, which supersede this medical policy.
Medical criteria: Not applicable.
Services determined to be not medically necessary — or medically necessary services that are non-covered benefits under the member's contract — may not be covered. Providers may not bill the member for such services unless the member was informed and provided written agreement in advance; refer to your participation agreement for applicable provisions.
Coding and Modifiers
| 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 |
| P1 | Physical Status Modifier P1 = ASA Class I: A normal, healthy individual. |
| P2 | Physical Status Modifier P2 = ASA Class II: An individual with mild systemic disease. |
| P3 | Physical Status Modifier P3 = ASA Class III: An individual with severe systemic disease. |
| P4 | Physical Status Modifier P4 = ASA Class IV: An individual with severe systemic disease that is a constant threat to life. |
| P5 | Physical Status Modifier P5 = ASA Class V: A moribund individual who is not expected to survive without the operation. |
| P6 | Physical Status Modifier P6 = ASA Class VI: A declared brain-dead individual whose organs are being harvested. |
Provider Actions and Requirements
Prior authorization: Not applicable
Prior authorization is not required for monitored anesthesia care (MAC) for gastrointestinal endoscopic procedures under this policy.
Contact provider call center for member-specific benefits
Verify member-specific benefits and eligibility by contacting the BCBSRI provider call center; benefits and eligibility are determined by the member's subscriber agreement or employer agreement which supersede this policy.
- Call the provider call center for information on member-specific benefits and eligibility.
Medical criteria: Not applicable
There is no separate medical-necessity checklist or medical criteria specified in this policy.
Additional provider instructions
For additional provider instructions and administrative details, refer to the policy notice that benefits and eligibility are governed by the member's subscriber agreement or employer agreement and to contact the provider call center for member-specific information.
Medical necessity documentation must be available on request
Member medical records must document that the services were medically necessary for the care provided and all documentation must be available to BCBSRI upon request.
- Maintain complete medical record documentation supporting medical necessity.
- Provide documentation to BCBSRI promptly if requested.
Call provider call center for member-specific benefits/eligibility
Providers must call the BCBSRI provider call center to determine member-specific benefits and eligibility before providing services.
Documentation audit may lead to denial or payment retraction
Failure to produce requested medical record documentation upon BCBSRI request may result in denial of the claim or retraction of payment.
Risk of non-payment or member billing for non-covered services
If services are determined to be not medically necessary (or are medically necessary but are non-covered benefits under the member's contract), the provider may not be paid and may not charge the member unless the member was informed and provided written agreement in advance.
- Obtain prior written agreement from the member before billing them directly for non-covered services.
Background
Monitored Anesthesia Care (MAC) is an anesthesia service provided by a qualified anesthesia provider that includes preprocedure assessment, intra-procedure management (including administration of sedatives and analgesics and support of vital functions), and postprocedure management. MAC involves a drug-induced depression of consciousness during which patients may still respond to verbal commands; the anesthesia provider must be prepared to manage all levels of sedation up to and including general anesthesia.
Indications for MAC during outpatient gastrointestinal endoscopic diagnostic or therapeutic procedures are based on patient and procedure characteristics that increase the risk of sedation-related complications or require deeper levels of sedation than typical moderate sedation. Examples include extremes of age, severe comorbidity (higher ASA physical status), morbid obesity, documented sleep apnea, certain airway/anatomic concerns, acute agitation or inability to cooperate, chronic opioid or benzodiazepine use, prior inadequate response to sedation, or procedures that are prolonged or technically complex (for example ERCP or therapeutic upper GI procedures).
This policy governs coverage and coding for MAC specifically for outpatient GI endoscopic procedures and emphasizes that benefits and eligibility are determined by the member's contract; providers should verify member-specific coverage before proceeding.
Definitions
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