Monitored Anesthesia Care
I am having trouble getting claims for MAC paid. What could be the problem?
First of all, each state has a LMRP for MAC (Monitored Anesthesia Care). Within these policies there are anesthesia codes for which no other documentation is necessary to support the necessity of MAC (column A codes). Column B codes are those that require a diagnosis or physical status indicator supporting the necessity of MAC. Each LMRP has a list of diagnosis codes which support the necessity of MAC (see exhibit A under “ICD-9 codes that support Medical Necessity”). Therefore, column B anesthesia requires an exhibit A diagnosis or an ASA physical status indicator of P3, P4 or P5 indicating that one of the diagnoses in Exhibit A is present. Sometimes providers do not include a physical status indicator or an appropriate diagnosis (such as code is not a covered diagnosis or is longer valid such as it must be coded to a higher level of specificity). These omissions would result in denials.
Modifier QS is used to reflect MAC was done. Modifier G8 is to be used on those anesthesia codes designated by an asterisk in the policy. This modifier indicates that the procedure was deep, complex, complicated or markedly invasive and performed on an area of the body that is very sensitive and includes the face (00100 and 00160), neck (00300), breast (00400), or male genitalia (00920) and for access to the central venous circulation (00532). The MAC modifier G9 is used with a column B procedure code to indicate that the patient has, or has had a severe cardiopulmonary condition or that there is significant risk of an exacerbation in a stable patient during the procedure. It is not necessary to use modifier QS in addition to G8 or G9, nor is it necessary to include a physical status indicator when modifier G8 or G9 is used.