How To Bill Monitored Anesthesia | CPT Codes, Billing Guide ICD 10 Codes

How To Bill Monitored Anesthesia | CPT Codes, Billing Guide & ICD 10 Codes

The billing guidelines for monitored anesthesia services can be found below. We have also listed the CPT codes, modifiers and ICD 10 codes that can be used for coding these services.

Coverage Indications, Limitations, And/Or Medical Necessity Of Monitored Anesthesia Care

With advances in modern medical technology, there has been a shift in supplying some surgical and diagnostic services to an ambulatory, outpatient or office setting.

Accompanying this, there has been a change in the provision of anesthesia services from the traditional general anesthetic to a combination of local, regional and certain mind-altering drugs.

This type of anesthesia is referred to as monitored anesthesia care (MAC) if directly provided by anesthesia personnel.

MAC requires careful and continuous evaluation of various vital physiologic functions and the diagnosis and treatment of any deviations. This type of anesthesia can be provided by a variety of qualified anesthesia personnel.

Coverage for MAC is allowed if the anesthesia service is medically reasonable and necessary and if the procedure for which MAC is given is itself a Medicare benefit and is medically reasonable and necessary.

  1. In keeping with the American Society of Anesthesiologists’ standards for monitoring, MAC should be provided by qualified anesthesia personnel, (anesthesiologists or qualified anesthetists such as certified registered nurse anesthetists or anesthesia assistants).

    These individuals must be continuously present to monitor the patient and provide anesthesia care.
  2. During MAC, the patient’s oxygenation, ventilation, circulation and temperature should be evaluated by whatever method is deemed most suitable by the attending anesthetist.

    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.
  3. The following CMS requirements for this type of anesthesia should be the same as for general anesthesia with regards to the performance of pre-anesthetic examination and evaluation, prescription of the anesthesia care required, the completion of an anesthesia record, the administration of necessary oral or parenteral medications and the provision of indicated post-operative anesthesia care.

    Appropriate documentation must be available to reflect pre and post-anesthetic evaluations and intraoperative monitoring.
  4. The MAC service rendered must be appropriate and medically reasonable and necessary.
  5. Anesthesia procedures listed in the CPT/HCPCS section are usually provided by the attending surgeon and are included in the global fee and are not separately billable. In certain instances, however, MAC provided by anesthesia personnel may be necessary for these procedures.

    This is true if there are one or more of the co-existing conditions present that are listed below under the ICD-10-CM code list. In this situation, the appropriate MAC modifier is QS, which should be billed along with the appropriate ICD-10-CM Code for the co-existing condition(s).

    Second the MAC modifier G8 can be used with the anesthesia services listed below and indicates that the surgical procedure is deep, complex, complicated or markedly invasive.

    These services include only procedures on the face (CPT 00100 and CPT 00160); head, neck, and posterior trunk (CPT 00300); breast (CPT 00400), or genitalia (CPT 00920) and for access to the central venous circulation (CPT 00532).

    These CPT codes themselves do not differentiate complexity. The MAC modifier G9 is used with an anesthesia code to indicate that the patient has a history of a severe cardiopulmonary condition.

In summary, MAC may be necessary and justified for the CPT/HCPCS procedures with the QS modifier if a co-existing condition exists, or if the procedure qualifies for a G8 modifier.

Reimbursement for MAC will be the same amount allowed for full general anesthesia services if all the requirements listed under these indications are met. No additional reimbursement is allowed with the use of modifiers (e.g., G8, G9).

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.

The presence of an underlying condition alone, as reported by an ICD-10-CM code, may not be sufficient evidence that MAC is necessary.

The medical condition must be significant enough to impact 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.

The following quote is from Guidelines for the use of deep sedation and anesthesia for GI endoscopy, Gastrointestinal Endoscopy, Volume 56, No. 5, 2002, p. 616. “

The routine assistance of an anesthesiologist for average risk patients undergoing standard upper and lower endoscopic procedures is not warranted and is cost prohibitive.”

This position of the gastrointestinal endoscopy community justifies this LMRP/LCD’s position that, to allow payment, MAC for these procedures must be justified by the presence of one of the listed conditions.

Modifiers

Modifier QS: Monitored anesthesia care (MAC)

Modifier G8: Monitored anesthesia care (MAC) for deep, complex, complicated, or markedly invasive surgical procedure.

Use G8 modifier for the following CPT codes for MAC: CPT 00100, CPT 00160, CPT 00300, CPT 00400 CPT 00532 and CPT 00920.

Modifier G9: Monitored anesthesia care (MAC) for patient who has history of severe cardio-pulmonary condition.

CPT Codes For Monitored Anesthesia Services

Below the CPT codes that can be used for monitored anesthesia services.

CPT 00100

00100 CPT Code Description: Anesthesia for procedures on salivary glands, including biopsy.

CPT 00124

00124 CPT Code Description: Anesthesia for procedures on external, middle, and inner ear including biopsy; otoscopy.

CPT 00148

00148 CPT Code Description: Anesthesia for procedures on eye; ophthalmoscopy.

CPT 00160

00160 CPT Code Description: Anesthesia for procedures on nose and accessory sinuses; not otherwise specified.

CPT 00164

00164 CPT Code Description: Anesthesia for procedures on nose and accessory sinuses; biopsy, soft tissue.

CPT 00300

00300 CPT Code Description: Anesthesia for all procedures on the integumentary system, muscles and nerves of head, neck, and posterior trunk, not otherwise specified.

CPT 00400

00400 CPT Code Description: Anesthesia for procedures on the integumentary system on the extremities, anterior trunk and perineum; not otherwise specified.

CPT 00410

00410 CPT Code Description: Anesthesia for procedures on the integumentary system on the extremities, anterior trunk and perineum; electrical conversion of arrhythmias.

CPT 00520

00520 CPT Code Description: Anesthesia for closed chest procedures; (including bronchoscopy) not otherwise specified.

CPT 00522

00522 CPT Code Description: Anesthesia for closed chest procedures; needle biopsy of pleura.

CPT 00524

00524 CPT Code Description: Anesthesia for closed chest procedures; pneumocentesis. CPT 00524 is an inpatient only procedure code.

CPT 00530

00530 CPT Code Description: Anesthesia for permanent transvenous pacemaker insertion.

CPT 00532

00532 CPT Code Description: Anesthesia for access to central venous circulation.

CPT 00702

00702 CPT Code Description: Anesthesia for procedures on upper anterior abdominal wall; percutaneous liver biopsy.

CPT 00920

00920 CPT Code Description: Anesthesia for procedures on male genitalia (including open urethral procedures); not otherwise specified. Be aware that this code can be used for males only.

CPT 01420

01420 CPT Code Description: Anesthesia for all cast applications, removal, or repair involving knee joint.

CPT 01730

01730 CPT Code Description: Anesthesia for all closed procedures on humerus and elbow.

CPT 01780

01780 CPT Code Description: Anesthesia for procedures on veins of upper arm and elbow; not otherwise specified.

CPT 01916

01916 CPT Code Description: Anesthesia for diagnostic arteriography/venography.

Do not report the 01916 CPT codes with therapeutic codes CPT 01924, CPT 01925, CPT 01926, CPT 01930, CPT 01931, CPT 01932 and CPT 01933.

CPT 01920

01920 CPT Code Description: Anesthesia for cardiac catheterization including coronary angiography and ventriculography (not to include Swan-Ganz catheter).

CPT 01922

01922 CPT Code Description: Anesthesia for non-invasive imaging or radiation therapy.

CPT 01999

01999 CPT Code Description: Unlisted anesthesia procedure(s)

ICD-10 Codes that Support Medical Necessity

A18.84 Tuberculosis of heart
A37.01 Whooping cough due to Bordetella pertussis with pneumonia
A37.11 Whooping cough due to Bordetella parapertussis with pneumonia
A37.81 Whooping cough due to other Bordetella species with pneumonia
A37.91 Whooping cough, unspecified species with pneumonia
A40.3* Sepsis due to Streptococcus pneumoniae
A48.1 Legionnaires’ disease
B25.0 Cytomegaloviral pneumonitis
B44.81 Allergic bronchopulmonary aspergillosis
D65 Disseminated intravascular coagulation [defibrination syndrome]
D66 Hereditary factor VIII deficiency
D67 Hereditary factor IX deficiency
D68.0 Von Willebrand’s disease
D68.1 Hereditary factor XI deficiency
D68.2 Hereditary deficiency of other clotting factors
D68.311 Acquired hemophilia
D68.312 Antiphospholipid antibody with hemorrhagic disorder
D68.318 Other hemorrhagic disorder due to intrinsic circulating anticoagulants, antibodies, or inhibitors
D68.32 Hemorrhagic disorder due to extrinsic circulating anticoagulants
D68.4 Acquired coagulation factor deficiency
D68.8 Other specified coagulation defects
D68.9 Coagulation defect, unspecified
E00.0 Congenital iodine-deficiency syndrome, neurological type
E00.1 Congenital iodine-deficiency syndrome, myxedematous type
E00.2 Congenital iodine-deficiency syndrome, mixed type
E00.9 Congenital iodine-deficiency syndrome, unspecified
E01.8 Other iodine-deficiency related thyroid disorders and allied conditions
E02 Subclinical iodine-deficiency hypothyroidism
E03.0 Congenital hypothyroidism with diffuse goiter
E03.1 Congenital hypothyroidism without goiter
E03.2 Hypothyroidism due to medicaments and other exogenous substances
E03.3 Postinfectious hypothyroidism
E03.8 Other specified hypothyroidism
E03.9 Hypothyroidism, unspecified
E05.00 Thyrotoxicosis with diffuse goiter without thyrotoxic crisis or storm
E05.01 Thyrotoxicosis with diffuse goiter with thyrotoxic crisis or storm
E05.10 Thyrotoxicosis with toxic single thyroid nodule without thyrotoxic crisis or storm
E05.11 Thyrotoxicosis with toxic single thyroid nodule with thyrotoxic crisis or storm
E05.20 Thyrotoxicosis with toxic multinodular goiter without thyrotoxic crisis or storm
E05.21 Thyrotoxicosis with toxic multinodular goiter with thyrotoxic crisis or storm
E05.30 Thyrotoxicosis from ectopic thyroid tissue without thyrotoxic crisis or storm
E05.31 Thyrotoxicosis from ectopic thyroid tissue with thyrotoxic crisis or storm
E05.40 Thyrotoxicosis factitia without thyrotoxic crisis or storm
E05.41 Thyrotoxicosis factitia with thyrotoxic crisis or storm
E05.80 Other thyrotoxicosis without thyrotoxic crisis or storm
E05.81 Other thyrotoxicosis with thyrotoxic crisis or storm
E05.90 Thyrotoxicosis, unspecified without thyrotoxic crisis or storm
E05.91 Thyrotoxicosis, unspecified with thyrotoxic crisis or storm
E08.01 Diabetes mellitus due to underlying condition with hyperosmolarity with coma
E08.11 Diabetes mellitus due to underlying condition with ketoacidosis with coma
E08.21 Diabetes mellitus due to underlying condition with diabetic nephropathy
E08.311 Diabetes mellitus due to underlying condition with unspecified diabetic retinopathy with macular edema
E08.319 Diabetes mellitus due to underlying condition with unspecified diabetic retinopathy without macular edema
E08.36 Diabetes mellitus due to underlying condition with diabetic cataract
E08.39 Diabetes mellitus due to underlying condition with other diabetic ophthalmic complication
E08.65 Diabetes mellitus due to underlying condition with hyperglycemia
E08.69 Diabetes mellitus due to underlying condition with other specified complication
E08.8 Diabetes mellitus due to underlying condition with unspecified complications
E09.01 Drug or chemical induced diabetes mellitus with hyperosmolarity with coma
E09.11 Drug or chemical induced diabetes mellitus with ketoacidosis with coma
E09.21 Drug or chemical induced diabetes mellitus with diabetic nephropathy
E09.311 Drug or chemical induced diabetes mellitus with unspecified diabetic retinopathy with macular edema
E09.319 Drug or chemical induced diabetes mellitus with unspecified diabetic retinopathy without macular edema
E09.36 Drug or chemical induced diabetes mellitus with diabetic cataract
E09.39 Drug or chemical induced diabetes mellitus with other diabetic ophthalmic complication
E09.65 Drug or chemical induced diabetes mellitus with hyperglycemia
E09.69 Drug or chemical induced diabetes mellitus with other specified complication
E09.8 Drug or chemical induced diabetes mellitus with unspecified complications
E10.10 Type 1 diabetes mellitus with ketoacidosis without coma
E10.11 Type 1 diabetes mellitus with ketoacidosis with coma
E10.21 Type 1 diabetes mellitus with diabetic nephropathy
E10.311 Type 1 diabetes mellitus with unspecified diabetic retinopathy with macular edema
E10.319 Type 1 diabetes mellitus with unspecified diabetic retinopathy without macular edema
E10.36 Type 1 diabetes mellitus with diabetic cataract
E10.39 Type 1 diabetes mellitus with other diabetic ophthalmic complication
E10.40 Type 1 diabetes mellitus with diabetic neuropathy, unspecified
E10.51 Type 1 diabetes mellitus with diabetic peripheral angiopathy without gangrene
E10.65 Type 1 diabetes mellitus with hyperglycemia
E10.69 Type 1 diabetes mellitus with other specified complication
E10.8 Type 1 diabetes mellitus with unspecified complications
E11.00 Type 2 diabetes mellitus with hyperosmolarity without nonketotic hyperglycemic-hyperosmolar coma (NKHHC)
E11.21 Type 2 diabetes mellitus with diabetic nephropathy
E11.311 Type 2 diabetes mellitus with unspecified diabetic retinopathy with macular edema
E11.319 Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema
E11.51 Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene
E11.65 Type 2 diabetes mellitus with hyperglycemia
E11.69 Type 2 diabetes mellitus with other specified complication
E11.8 Type 2 diabetes mellitus with unspecified complications
E15 Nondiabetic hypoglycemic coma
E16.0 Drug-induced hypoglycemia without coma
E16.1 Other hypoglycemia
E16.3 Increased secretion of glucagon
E16.4 Increased secretion of gastrin
E16.8 Other specified disorders of pancreatic internal secretion
E16.9 Disorder of pancreatic internal secretion, unspecified
E20.0 Idiopathic hypoparathyroidism
E20.8 Other hypoparathyroidism
E20.9 Hypoparathyroidism, unspecified
E21.0 Primary hyperparathyroidism
E21.1 Secondary hyperparathyroidism, not elsewhere classified
Group 1 Medical Necessity ICD-10 Codes Asterisk Explanation: * A40.1 – A41.9 Acute sepsis supported by diagnosis
* E05.00 – E89.00-Severe metabolic disorders
* E86.0-E87.8 Electrolyte imbalance supported by sodium, potassium or calcium levels, etc, outside normal limits
* E66.01 Two times ideal body weight
* F01.50-F25.8 Brain syndrome/dementia with confusion or combative behavior and various type psychoses (supported by diagnosis)
* F41.0-F41.8 Supported by diagnosis, type and need for and response to sedative medication
* F11.20-F19.288 Acute detoxification state
* F10.10-F10.129 Acute drunkenness
* F12.10-F12.90 Acute detoxification state
* F16.10–F16.90 Acute detoxification state
* F13.10–F13.90 Acute detoxification state
* F11.10–F11.90 Acute detoxification state
* F14.10–F14.90 Acute detoxification state
* F15.10–F15.90 Acute detoxification state
* F19.10–F19.90 Acute detoxification state
* I10 Unstable (systolic pressure over 180, or diastolic over 110 and on more than two anti-hypertensive medications)
* I11.0–I11.9 Acute, multiple medications, etc.
* I60.01-I167.841 Acute condition supported by diagnosis and treatment
* K70.11-K76.89 Hepatic failure (bilirubin greater than 3)
* K92.2) Massive gastrointestinal bleeding (over 500 cc blood loss by history as an example)
* Z93.0 Supported by history, diagnosis
* Z79.891 Use of high-risk medication when that medication may affect the choice of anesthesia

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