CurrentSelectHealthPolicy 641

Office-Based Anesthesia (Monitored Anesthesia Care, Moderate/Deep Sedation)

SelectHealth policy defining coverage criteria for office-based anesthesia services (MAC, moderate sedation/analgesia, deep sedation, general and regional anesthesia definitions), applicable CPT/HCPCS codes, provider qualifications (including CMS credentialing/ASA modifiers), and plan-specific applicability for Commercial, Medicare (CMS), and Community Care (Medicaid) products.

Policy Summary

PayerSelectHealth

PolicyOffice-Based Anesthesia (Monitored Anesthesia Care, Moderate/Deep Sedation)

Policy CodePolicy 641

Change TypeRevised (2023, 2026)

Effective DateApr 1, 2020

Next Review Date

Key ActionEnsure anesthesia medications (MAC, regional, deep sedation, general) are administered only by providers credentialed to administer anesthesia per CMS and document credentialing for coverage.

SourceLink

POLICY UPDATE CHANGES

2/17/23 - For Commercial Plan Policy, updated wording in criterion #Ai to 'Clinical procedures that are prolonged, complex, or painful that require more than a local anesthetic.'

2/16/26 - For Commercial Plan Policy, added 'Anesthesia Assistant' to list of eligible providers and removed 'restoration' from criterion referencing lengthy pediatric procedures.

2Recent substantive revisions (2023, 2026)

15CPT/HCPCS codes listed

3Product lines referenced

Coverage Summary

Overview: Office-Based Anesthesia (Monitored Anesthesia Care, Moderate/Deep Sedation, General and Regional Anesthesia) — SelectHealth policy defining coverage criteria for MAC, moderate sedation/analgesia, deep sedation, general and regional anesthesia in office/outpatient settings.

Subject: Office-Based Anesthesia (Monitored Anesthesia Care, Moderate/Deep Sedation).

Effective date: 2020-04-01.

Last review: 2026-02-03.

Policy metadata

policy_number641

effective_date2020-04-01

last_review2026-02-03

product_lines_referencedCommercial, Medicare (CMS), Community Care (Medicaid)

Product-line Applicability & Medicare/Medicaid Notes

Documentation Required

Medicare and Medicaid applicability

For Medicare, follow CMS coverage determinations. If CMS has not adopted a determination and InterQual criteria are not available, the Select Health Commercial policy applies. For Select Health Community Care (Medicaid), policies typically align with State of Utah Medicaid and use InterQual where applicable; NCD/LCD or Select Health commercial policies may be used in some situations. Document which guideline (CMS, Utah Medicaid/InterQual, or Commercial policy) was used to make the coverage decision.

Relevant CPT/HCPCS/Modifier Codes

Covered CPT codes for anesthesia/ MAC / sedationCPTCovered

00731	Anesthesia for upper gastrointestinal endoscopic procedures, endoscope introduced proximal to duodenum; not otherwise specified
00732	Anesthesia for upper gastrointestinal endoscopic procedures; ERCP
00811	Anesthesia for lower intestinal endoscopic procedures; not otherwise specified
00811PT	Anesthesia for lower intestinal endoscopic procedures, converted to diagnostic test or other procedure
00812	Anesthesia for lower intestinal endoscopic procedures; screening colonoscopy
00813	Anesthesia for combined upper and lower gastrointestinal endoscopic procedures
99151	Moderate sedation by same physician; initial 15 minutes, patient <5 yrs
99152	Moderate sedation by same physician; initial 15 minutes, patient >=5 yrs
99153	Moderate sedation by same physician; each additional 15 minutes
99155	Moderate sedation by a clinician other than the performing clinician; initial 15 minutes, patient <5 yrs

1–10 of 13

1/2

Modifiers (ASA/P-status and other anesthesia modifiers)Modifier

P1	ASA I - normal healthy patient
P2	ASA II - mild systemic disease
P3	ASA III - severe systemic disease
P4	ASA IV - severe systemic disease constant threat to life
P5	ASA V - moribund patient not expected to survive
P6	ASA VI - declared brain-dead donor
G8	Monitored anesthesia care (MAC) for deep complex, complicated, or markedly invasive surgical procedure
QS	Monitored anesthesiology care service

HCPCS anesthesia/sedation codesHCPCSCovered

D9222	Deep sedation/general anesthesia, first 15 minutes
D9223	Deep sedation/general anesthesia, each subsequent 15 minute increment
D9239	Intravenous moderate (conscious) sedation/analgesia, first 15 minutes
D9243	Intravenous moderate (conscious) sedation/analgesia, each subsequent 15 minute increment
D9248	Non-intravenous conscious sedation

Billing Rule

Procedure-specific code usage for colonoscopy/EGD

Use the specified anesthesia CPT codes for colonoscopy and EGD as follows:

Use 00812 for preventive/screening colonoscopies.
Use 00811 for non-screening colonoscopies (report appropriate P modifiers reflecting ASA status).
Use 00731 and 00732 for diagnostic EGDs (report appropriate P modifiers reflecting ASA status).
Use 00813 for combined EGD and colonoscopy (report appropriate P modifiers reflecting ASA status).

Documentation Required

Use of ASA 'P' Modifiers

When billing MAC or other anesthesia services, report the appropriate ASA 'P' modifier (P1–P6) to reflect the patient's ASA classification.

Provider Actions & Billing Risk

Prior Authorization

Credentialing requirement for anesthesia administration

MAC, regional, deep sedation, and general anesthesia medications must be administered only by providers credentialed to administer anesthesia as defined by CMS. Documentation of appropriate credentialing is required for coverage.

Denial Risk

MAC limited to CMS-specified outpatient procedures

Monitored Anesthesia Care (MAC) will only be covered for procedures listed in the CMS outpatient procedure listings. Claims for MAC provided for procedures outside the CMS-listed outpatient procedures risk denial.

Definitions & Evidence

General Anesthesia: Drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation; ventilatory function is often impaired and airway support or positive pressure ventilation may be required. Certain agents used for procedural sedation (e.g., propofol, ketamine, etomidate, methohexital, pentothal) are classified as general anesthetic agents regardless of dose or route and must be administered only by providers credentialed to administer anesthesia as defined by CMS.

Monitored Anesthesia Care (MAC): Anesthesia care that includes patient monitoring by a practitioner qualified to administer anesthesia. Indications depend on the procedure, patient clinical condition, and potential need to convert to general or regional anesthesia. Deep sedation/analgesia is included within MAC.

Moderate Sedation/Analgesia ('Conscious Sedation'): Drug-induced depression of consciousness during which patients respond purposefully to verbal commands; no interventions required to maintain a patent airway and spontaneous ventilation is adequate. CMS and ASA do not define moderate/conscious sedation as 'anesthesia'; moderate sedation should be administered consistent with ASA 2018 Practice Guidelines for Moderate Procedural Sedation.

Reference Type	Citation
Reference	CMS Manual System Pub. 100-07 Transmittal 74, Dec 2, 2011
Guideline	ASA 2018 Practice Guidelines for Moderate Procedural Sedation

Background: The policy defines anesthesia levels (general, regional, MAC, deep, moderate, minimal, local) and expects that MAC, regional, deep sedation, and general anesthesia medications be administered only by providers credentialed to administer anesthesia per CMS; documentation of appropriate credentialing is required for coverage.

Pharmacologic agents: Specific agents such as propofol and ketamine are considered general anesthetic agents when used for procedural sedation and must be administered by credentialed anesthesia providers. Ketamine guidance: ketamine has distinct pharmacology, does not typically cause loss of airway reflexes but can cause blood pressure changes and increased secretions; consensus guidance limits higher-dose ketamine infusions to providers trained in induction and maintenance of ketamine with airway management training (e.g., anesthesiologists, critical care, emergency medicine, pain physicians with appropriate credentials).

Revision History

2023-02-17revision

For Commercial Plan Policy, updated wording in criterion #Ai to 'Clinical procedures that are prolonged, complex, or painful that require more than a local anesthetic.' (Wording change to align with current clinical standards.)

2026-02-16revisionLatest

For Commercial Plan Policy, added 'Anesthesia Assistant' to list of eligible providers and removed 'restoration' from the pediatric criterion referencing lengthy procedures. (Expanded eligible provider list and clarified pediatric criterion.)