Monitored Anesthesia Care

This LCD supplements but does not replace, modify or supersede existing Medicare applicable National Coverage Determinations (NCDs) or payment policy rules and regulations for monitored anesthesia care services. Federal statute and subsequent Medicare regulations regarding provision and payment for medical services are lengthy. They are not repeated in this LCD. Neither Medicare payment policy rules nor this LCD replace, modify or supersede applicable state statutes regarding medical practice or other health practice professions acts, definitions and/or scopes of practice. All providers who report services for Medicare payment must fully understand and follow all existing laws, regulations and rules for Medicare payment for monitored anesthesia care services and must properly submit only valid claims for them. Please review and understand them and apply the medical necessity provisions in the policy within the context of the manual rules. Relevant CMS manual instructions and policies may be found in the following Internet-Only Manuals (IOMs) published on the CMS Web site:

IOM Citations:

• CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Section 50 Payment for Anesthesiology Services and Section 140.3 Anesthesia Fee Schedule Payment for Qualified Nonphysician Anesthetists
• CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 13, Section 13.5.4 Reasonable and Necessary Provision in an LCD

Social Security Act (Title XVIII) Standard References:

• Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim.
• Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no Medicare payment shall be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury.
• Title XVIII of the Social Security Act, Section 1862(a)(7). This section excludes routine physical examinations.

Notice: Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis and subsequent medical review audits.

• In keeping with the American Society of Anesthesiologists’ standards for monitoring, MAC should be provided by qualified anesthesia personnel in accordance with individual state licensure. These individuals must be continuously present to monitor the patient and provide anesthesia care.
• During MAC, the patient’s oxygenation, ventilation, circulation and temperature should be evaluated by whatever methods are deemed most suitable by the attending anesthetist. It is anticipated that newer methods of non-invasive monitoring such as pulse oximetry and capnography will be frequently relied upon. Close monitoring is necessary to anticipate the need for general anesthesia administration or for the treatment of adverse physiologic reactions such as hypotension, excessive pain, difficulty breathing, arrhythmias, adverse drug reactions, etc. In addition, the possibility that the surgical procedure may become more extensive and/or result in unforeseen complications requires comprehensive monitoring and/or anesthetic intervention.
• Please see CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Sections 50 and 140.3 for CMS requirements for this type of anesthesia.
• Anesthesia procedures listed in the “CPT/HCPCS Codes” section of the related Local Coverage Article Billing and Coding: Monitored Anesthesia Care (A57361), are examples of those that are usually provided by the attending surgeon and are included in the global fee and are not separately billable. In certain instances, MAC provided by anesthesia personnel may be reasonable and necessary for procedures that are generally provided by the attending surgeon if certain conditions or situations are present. In these situations, MAC may be necessary for these active and serious accompanying situations or conditions to ensure smooth anesthesia (and surgery) by the prevention of adverse physiologic complications. Refer to the related billing and coding article for diagnoses that support the use of MAC in these situations. Special conditions or criteria must be supported by documentation in the medical record.
• The provision of quality MAC is mandatory and requires the same expertise and the same effort (work) as required in the delivery of a general anesthetic. If the requirements are not fulfilled or the procedures are unnecessary, payment will be denied in full.
• For procedures that do not usually require anesthesia services, MAC could be covered when the patient’s condition requires the presence of qualified anesthesia personnel to perform monitored anesthesia in addition to the physician performing the procedure, and is so documented in the patient’s medical record.
• The presence of an underlying condition alone may not be sufficient evidence that MAC is necessary. The medical condition must be significant enough to impact on the need to provide MAC such as the patient being on medication or being symptomatic, etc. The presence of a stable, treated condition, of itself, is not necessarily sufficient.

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N/A

Refer to the Local Coverage Article Billing and Coding: Monitored Anesthesia Care (A57361) for all coding information.

Documentation Requirements

1. All documentation must be maintained in the patient’s medical record and made available to the contractor upon request.
2. Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.
3. The medical record documentation must support the medical necessity of the services as stated in this policy.
4. Hospital, outpatient, ASC or office records should clearly document the reason for the MAC (e.g., the patient’s condition that requires the appropriate anesthesia; indications the procedure performed was deep, complex, complicated or markedly invasive).
5. The medical record should include a pre-anesthesia evaluation including a history and physical exam.
6. The medical record should include evidence of continuous monitoring of the patient’s oxygenation, ventilation, circulation and temperature.
7. The medical record should include a post-anesthesia evaluation of the patient including any unusual events or complications and the patient’s status on discharge.

Utilization Guidelines

In accordance with CMS Ruling 95-1 (V), utilization of these services should be consistent with locally acceptable standards of practice.

Contractor is not responsible for the continued viability of websites listed.

Contractor Medical Directors

JL LCD L27489 Monitored Anesthesia Care (MAC)

Other Contractor Local Coverage Determinations

“Monitored Anesthesia Care,” TrailBlazer LCD, (00400) L15969, (00900) L16418.

“Monitored Anesthesia Care,” Noridian Administrative Services, LLD LCD, (CO) (L23737).

“Monitored Anesthesia Care,” Arkansas BlueCross BlueShield (Pinnacle) LCD, (NM, OK) L14639.

Original JH ICD-9 Source LCD L32628, Monitored Anesthesia Care

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9. Singh H, Poluha W, Cheang M, et al. Propofol for sedation during colonoscopy (Review). The Cochrane Collaboration 2011. http://www.thecochranelibrary.com.
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