Local Coverage Determination (LCD)

Monitored Anesthesia Care

L35049

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Contractor Information

LCD Information

Document Information

LCD ID
L35049
LCD Title
Monitored Anesthesia Care
Proposed LCD in Comment Period
N/A
Source Proposed LCD
N/A
Original Effective Date
For services performed on or after 10/01/2015
Revision Effective Date
For services performed on or after 10/17/2019
Revision Ending Date
N/A
Retirement Date
N/A
Notice Period Start Date
N/A
Notice Period End Date
N/A
AMA CPT / ADA CDT / AHA NUBC Copyright Statement

CPT codes, descriptions and other data only are copyright 2020 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.

Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

Current Dental Terminology © 2020 American Dental Association. All rights reserved.

Copyright © 2013 - 2021, the American Hospital Association, Chicago, Illinois. Reproduced by CMS with permission. No portion of the American Hospital Association (AHA) copyrighted materials contained within this publication may be copied without the express written consent of the AHA. AHA copyrighted materials including the UB-04 codes and descriptions may not be removed, copied, or utilized within any software, product, service, solution or derivative work without the written consent of the AHA. If an entity wishes to utilize any AHA materials, please contact the AHA at 312-893-6816. Making copies or utilizing the content of the UB-04 Manual, including the codes and/or descriptions, for internal purposes, resale and/or to be used in any product or publication; creating any modified or derivative work of the UB-04 Manual and/or codes and descriptions; and/or making any commercial use of UB-04 Manual or any portion thereof, including the codes and/or descriptions, is only authorized with an express license from the American Hospital Association. To license the electronic data file of UB-04 Data Specifications, contact Tim Carlson at (312) 893-6816. You may also contact us at ub04@aha.org.

CMS National Coverage Policy

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.

Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity


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.
Summary of Evidence

N/A

Analysis of Evidence (Rationale for Determination)

N/A

General Information

Associated Information


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.

Sources of Information

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

Bibliography
  1. AGA Institute. AGA Institute Review of Endsocopic Sedation. Gastroenterology 2007; 133:675-701.
  2. American Society of Anesthesiology Task Force. Practice Guidelines for Sedation and Analgesia by Non-Anesthesiologists. Anesthesiology, 2002; 96(4): 1004-1017.
  3. ASGE Practice Guidelines. Sedation and Anesthesia in GI Endoscopy. Gastrointestinal Endoscopy 2008; 86(5): 815-826.
  4. ASGE Practice Guidelines. Guidelines for Safety in the Gastrointestinal Endoscopy Unit. Gastrointestinal Endoscopy. 2014; 79(3): 363-372.
  5. CDC Website on Colorectal Cancer @http://www.cid.gov/cancer/colorectal/statistics/state.htm
  6. Inadomi JM, Gunnarsson CL, Rizzo JA. Projected increased growth rate of anesthesia professional-delivered sedation for colonoscopy and EGD in the United States: 2009 to 2015. Gastrointestinal Endoscopy. 2010; 72(3) 580-6.
  7. Liu H, Waxman DA, Main R, et al. Utilization of Anesthesia Services During Outpatient Endoscopies and Colonoscopies and Associated Spending in 2003-2009. JAMA. 2012; 307(11): 1178-1184
  8. Meining A, Semmler V, Kassem A, et al. The effect of sedation on the quality of upper gastrointestinal endoscopy: an investigator-blinded, randomized study comparing propofol with midazolam. Endoscopy. 2007; 39: 345-349.
  9. Singh H, Poluha W, Cheang M, et al. Propofol for sedation during colonoscopy (Review). The Cochrane Collaboration 2011. http://www.thecochranelibrary.com.
  10. Triantafillidis JK, Merikas E, Nikolakis D, et al. Sedation in gastrointestinal endoscopy: Current issues. World Journal of Gastroenterology. 2013; 19(4); 463-481.

Revision History Information

Revision History DateRevision History NumberRevision History ExplanationReasons for Change
10/17/2019 R12

LCD revised and published on 10/17/2019. All codes and related coding information have been moved and placed in the related billing and coding article, A57361, consistent with Change Request (CR) 10901. NCD and manual language has been removed from the Coverage Guidance section of the policy and replaced with applicable references. The sources have been moved to the bibliography section and numbered. There has been no change in coverage with this revision.

  • Other (Changes in response to CMS change request)
04/11/2019 R11

LCD revised and published on 04/11/2019 in response to CMS Change Request 10901 to remove reasonable and necessary IOM language and update the CMS IOM citations. CMS IOM reference for Publication 100-09 pertains to coding therefore it has been removed from the LCD. There has been no change in content to the LCD.

  • Other (Changes in response to CMS change request)
10/01/2018 R10

LCD revised and published on 10/25/2018 effective for dates of service on and after 10/01/2018 to reflect the Annual ICD-10-CM Code Updates. The following ICD-10-CM code(s) have been deleted and therefore removed from the LCD: F53 and I63.8. The following ICD-10-CM code(s) have been added to the LCD Group 1 codes: F12.23, F12.93, F53.1, I63.81, and I63.89. The following ICD-10-CM code(s) have undergone a descriptor change: I63.219, I63.239, I63.333, and I63.343.

At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; therefore, not all the fields included on the LCD are applicable as noted in this policy.

  • Revisions Due To ICD-10-CM Code Changes
06/28/2018 R9

LCD updated on 06/28/2018 for administrative purposes. No changes have been made to the LCD content.

At this time the 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination, therefore, not all the fields included in the LCD are applicable as noted in this policy.

  • Other (Administrative, No Content Update)
01/01/2018 R8

LCD revised and published on 01/25/2018 effective for dates of service on and after 01/01/2018 to reflect the annual CPT/HCPCS code updates. The following CPT/HCPCS code(s) have been added to the Group 1 codes: 00731 and 00732. The following CPT/HCPCS code(s) have been deleted and therefore removed from the LCD: 00740 and 01682. For the following CPT/HCPCS code(s) either the short description and/or the long description has been changed. Depending on which description is used in this LCD, there may not be any change in how the code displays in the document: 01680.

At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; therefore, not all the fields included on the LCD are applicable as noted in this policy.

  • Revisions Due To CPT/HCPCS Code Changes
10/01/2017 R7

LCD revised and published on 10/05/2017 effective for dates of service on and after 10/01/2017 to reflect the Annual ICD-10-CM Code Updates. The Group 1 asterisk note for ICD-10-CM code  I50.9 has been revised to include the new ICD-10-CM code additions.

The following ICD-10-CM code(s) have been added to the LCD:
Group 1 codes E11.10, E11.11, G12.25, I21.9, I50.810*, I50.811*, I50.812*, I50.813*, I50.814*, I50.82*, I50.83*, I50.84*, and I50.89*.

The following ICD-10-CM code(s) have undergone a descriptor change:
Group 1 codes F41.0, I50.1, I63.211, I63.212, I63.22, I63.323, I63.333, I63.513, I63.523, and I63.533.

At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; therefore, not all the fields included on the LCD are applicable as noted in this policy.

  • Revisions Due To ICD-10-CM Code Changes
10/01/2016 R6 LCD revised and published on 09/29/2016 effective for dates of service on and after 10/01/2016 to reflect the ICD-10 Annual Code Updates. The following ICD-10 code(s) have been deleted and therefore removed from the LCD: Group 1 codes F32.8, F34.8, H35.32, I60.20, I60.21, I60.22, K85.0, K85.1, K85.2, K85.3, K85.8, and K85.9. The following ICD-10 code(s) have been added to the LCD: Group 1 codes F32.89, F34.81, F34.89, H35.3210, H35.3211, H35.3212, H35.3213, H35.3220, H35.3221, H35.3222, H35.3223, H35.3230, H35.3231, H35.3232, H35.3233, I60.2, I63.013, I63.033, I63.113, I63.133, I63.213, I63.233, I63.313, I63.323, I63.333, I63.343, I63.413, I63.423, I63.433, I63.443, I63.513, I63.523, I63.533, I63.543, K85.00, K85.01, K85.02, K85.10, K85.11, K85.12, K85.20, K85.21, K85.22, K85.30, K85.31, K85.32, K85.80, K85.81, K85.82, K85.90, K85.91, and K85.92. The Group 1 asterisk note has been revised to reflect the ICD-10 updated K diagnoses codes.
  • Revisions Due To ICD-10-CM Code Changes
10/01/2015 R5 LCD revised and published on 07/14/2016 to add missing asterisk to Group 1 ICD-10 code I10 effective for dates of service on and after 10/01/2015.
  • Typographical Error
10/01/2015 R4 LCD revised and published on 10/29/2015 for dates of service on and after 10/01/2015 to add several ICD-10 codes for higher specificity to Group 1 as covered diagnoses.
  • Other (Clarification)
10/01/2015 R3 LCD revised and published on 06/25/2015 to add additional sources that were reviewed in response to a ICD-9 LCD L32628 reconsideration request for an additional diagnosis code. No other change was made to the policy.
  • Reconsideration Request
10/01/2015 R2 LCD revised to create uniform LCD with other MAC jurisdiction.
  • Creation of Uniform LCDs With Other MAC Jurisdiction
10/01/2015 R1 LCD revised and published on 08/14/2014 to reflect changes to the annual ICD-10 updates. ICD-10 codes T40.1X5A and T40.8X5A were removed from the policy.
  • Revisions Due To ICD-10-CM Code Changes

Associated Documents

Attachments
N/A
Related Local Coverage Documents
Articles
A57361 - Billing and Coding: Monitored Anesthesia Care
Related National Coverage Documents
N/A
Public Versions
Updated On Effective Dates Status
10/11/2019 10/17/2019 - N/A Currently in Effect You are here
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

N/A

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