CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Monitored Anesthesia Care (MAC) and Moderate (Conscious) Sedation coverage

Defines coverage and reimbursement policy for monitored anesthesia care (MAC) and moderate (conscious) sedation in outpatient settings for Blue Cross Blue Shield - Rhode Island Medicare Advantage and Commercial products, including which CPT codes are separately reimbursed versus not separately reimbursed. Does not require prior authorization.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyMonitored Anesthesia Care (MAC) and Moderate (Conscious) Sedation coverage

Policy CodePolicy N/A

Change TypeClarified (no material coverage changes)

Effective DateJan 1, 2017

Next Review Date

Key ActionNo prior authorization review is required for monitored anesthesia care or moderate sedation services per this policy.

SourceLink

POLICY UPDATE CHANGES

Policy last updated 10/04/2023; published in Provider Update December 2023.

1Prior authorization requirement

00100-01999, 99155-99157, 99151-99153Key CPT codes referenced

Separate vs same providerReimbursement determinant

Coverage Summary

Coverage and Reimbursement Criteria

Policy Statement - Coverage and Reimbursement Rules

Covered and reimbursed when criteria below are met:

ALL of the following

Monitored anesthesia care (MAC) is covered and separately reimbursed for Medicare Advantage Plans and Commercial Products using anesthesia CPT codes 00100-01999
Prior authorization review is not required

ALL of the following

Report anesthesia codes 00100-01999 for MAC
See Monitored Anesthesia Care (MAC) Coding

Policy applicability

Moderate (Conscious) Sedation - Separate Reimbursement by Provider Relationship

Coverage and reimbursement depend on whether sedation is provided by a separate provider or the same provider:

Separate provider

Applicable CPT codes for separate-provider moderate sedation
99155/99156/99157

Same provider

Applicable CPT codes for same-provider moderate sedation
99151/99152/99153

Coding summary

Separate vs not-separately reimbursed codes: 99155-99157 vs 99151-99153

Facility setting - Separate reimbursement eligibility

When performed in a facility setting:

ALL of the following

Applicable specialties for second-provider reimbursement
- Critical Care (specialty code 079)
- Emergency medicine (specialty code 093)
- Anesthesia specialties
- Another physician who is credentialed/qualified to perform these services

When billing in a facility setting, documentation must justify need for dedicated separate physician for second-provider reimbursement

Coding

Covered Anesthesia CodesCPTCovered

00100-01999

Anesthesia codes (Monitored Anesthesia Care)

Moderate (Conscious) Sedation - Covered and Separately Reimbursed (when provided by second provider)CPTCovered

99155	Moderate sedation services by provider other than the performing provider; initial 15 minutes; patient younger than 5 years
99156	Moderate sedation services by provider other than the performing provider; initial 15 minutes; patient age 5 years or older
99157	Moderate sedation services by provider other than the performing provider; each additional 15 minutes

Moderate (Conscious) Sedation - Covered but Not Separately Reimbursed (when provided by same performing provider)CPTNot Covered

99151	Moderate sedation services by the same performing provider; requiring presence of independent trained observer to assist in monitoring
99152	Moderate sedation services by the same performing provider; initial 15 minutes; patient age 5 years or older / or patient younger than 5 years as described
99153	Moderate sedation services by the same performing provider; each additional 15 minutes

Provider Actions & Billing Rules

Prior Authorization

Prior authorization not required

No prior authorization review is required for monitored anesthesia care or moderate sedation services per this policy.

Billing Rule

Separate reimbursement rules for sedation codes

Report anesthesia codes 00100-01999 for MAC. Moderate sedation codes 99155, 99156, and 99157 are eligible for separate reimbursement when provided by a second provider; codes 99151, 99152, and 99153 are not separately reimbursed when provided by the same performing provider.

00100-01999
99155
99156
99157
99151
99152
99153

Documentation Required

Facility second-provider justification

When billing moderate sedation codes separately in a facility setting, documentation should justify that the patient's medical condition required the dedication of a separate physician and that the second provider is of an applicable specialty or credentialed/qualified to perform these services.

99155
99156
99157
Applicable specialties: Critical Care (079), Emergency medicine (093), Anesthesia, or another credentialed/qualified physician

Background

Policy defines monitored anesthesia care (MAC) per American Society of Anesthesiologists guidance and describes the ASA levels of sedation: minimal sedation (anxiolysis), moderate sedation/analgesia (conscious sedation), deep sedation/analgesia, and general anesthesia. Outpatient diagnostic and therapeutic procedures (for example endoscopy, colonoscopy, bronchoscopy, and interventional procedures) often rely on varying degrees of sedation; moderate sedation is generally sufficient for many diagnostic and uncomplicated therapeutic procedures, but because sedation is a continuum practitioners must be prepared to rescue patients whose sedation becomes deeper than intended. Personnel administering sedation and anesthesia in outpatient settings should be qualified and appropriately trained, and those providing MAC should be prepared and qualified to convert to anesthesia when necessary.

Monitored Anesthesia Care (MAC) is defined: “Specific anesthesia service for a diagnostic or therapeutic procedure including indications based on the nature of the procedure, the patient's clinical condition and/or the potential need to convert to general or regional anesthetic; includes pre-procedure, intra-procedure and post-procedure anesthesia management; provider prepared to convert to anesthesia as needed.”

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyMonitored Anesthesia Care (MAC) and Moderate (Conscious) Sedation coverage

Policy CodePolicy N/A

Change TypeClarified (no material coverage changes)

Effective DateJan 1, 2017

Next Review Date

Key ActionNo prior authorization review is required for monitored anesthesia care or moderate sedation services per this policy.

SourceLink

On This Page

OpenPayer

Monitored Anesthesia Care (MAC) and Moderate (Conscious) Sedation coverage

Coverage Summary

Coverage and Reimbursement Criteria

Coding

Provider Actions & Billing Rules

Background

Revision History