Clinical UM Guideline
|Subject:||Anesthesia Services and Moderate (“Conscious”) Sedation|
|Guideline #:||CG-MED-21||Current Effective Date:||01/01/2016|
|Status:||Reviewed||Last Review Date:||05/07/2015|
This document addresses the medical necessity of anesthesia services. Anesthesia services include all services associated with the administration and monitoring of analgesia or anesthesia in order to produce partial or complete loss of sensation. Examples of various methods of anesthesia include general anesthesia, regional anesthesia, monitored anesthesia care (MAC), moderate sedation ("conscious sedation"), and local infiltration or topical application.
This document does not address anesthesia services during gastrointestinal endoscopic procedures. See: CG-MED-34 Anesthesia Services for Gastrointestinal Endoscopic Procedures.
This document does not address whether or not reimbursement is provided for the anesthesia service and is not intended to explain the billing and reimbursement of anesthesia.
General Anesthesia or Regional Anesthesia
Administration of general or regional anesthesia is considered medically necessary when both of the following criteria are met:
If general or regional anesthesia is requested for a procedure typically not requiring either of these levels of anesthesia service, a medical necessity review will be performed. This review will assess not only the procedure involved, but also other individual-specific issues, such as age, mental status, ability to cooperate, co-morbid conditions, and general medical status.
Monitored Anesthesia Care (MAC)
Monitored anesthesia care (MAC) is considered medically necessary when all of the following criteria are met:
Anesthesia Services including MAC
For surgical procedures which do not usually require anesthesia services, anesthesia services including monitored anesthesia care (MAC) are considered medically necessary when the individual'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. The medical condition must be significant enough to impact the need to provide anesthesia services including MAC. Complex procedures and procedures in high-risk individuals may justify the use of an anesthesiologist or anesthetist to provide conscious sedation or deep sedation. See Appendix for physical status classifications. The presence of a stable, treated condition of itself is not necessarily sufficient.
Moderate ("Conscious") Sedation
Moderate sedation ("conscious sedation") ordered by the attending physician and administered by the surgeon or physician performing the procedure or an independent trained practitioner is considered medically necessary when alternative types of anesthesia, sedation, or analgesia are not appropriate.
The administration of local anesthesia is considered medically necessary when alternative types of anesthesia, sedation, or analgesia are not appropriate.
Standby Anesthesia Services
Standby anesthesia service is when the anesthesiologist would be immediately available if a clinical need should arise but the anesthesiologist may be elsewhere performing other duties. Stand-by anesthesia is considered medically necessary when a procedure, which does not normally require anesthesia services, has a significant potential for catastrophic complications or potential for the need of other intervention that would require immediate availability of general anesthesia.
Not Medically Necessary:
Anesthesia services are considered not medically necessary for all other indications.
The following codes for treatments and procedures applicable to this document are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.
|00100-00222||Anesthesia for procedures on the head [includes codes 00100, 00102, 00103, 00104, 00120, 00124, 00126, 00140, 00142, 00144, 00145, 00147, 00148, 00160, 00162, 00164, 00170, 00172, 00174, 00176, 00190, 00192, 00210, 00211, 00212, 00214, 00215, 00216, 00218, 00220, 00222]|
|00300-00352||Anesthesia for procedures on the neck [includes codes 00300, 00320, 00322, 00326, 00350, 00352]|
|00400-00474||Anesthesia for procedures on the thorax [includes codes 00400, 00402, 00404, 00406, 00410, 00450, 00454, 00470, 00472, 00474]|
|00500-00580||Anesthesia for intrathoracic procedures [includes codes 00500, 00520, 00522, 00524, 00528, 00529, 00530, 00532, 00534, 00537, 00539, 00540, 00541, 00542, 00546, 00548, 00550, 00560, 00561, 00562, 00563, 00566, 00567, 00580]|
|00600-00670||Anesthesia for procedures on spine and spinal cord [includes codes 00600, 00604, 00620, 00625, 00626, 00630, 00632, 00635, 00640, 00670]|
|00700-00797||Anesthesia for procedures on upper abdomen [includes codes 00700, 00702, 00730, 00750, 00752, 00754, 00756, 00770, 00790, 00792, 00794, 00796, 00797]|
|00800-00882||Anesthesia for procedures on lower abdomen [includes codes 00800, 00802, 00820, 00830, 00832, 00834, 00836, 00840, 00842, 00844, 00846, 00848, 00851, 00860, 00862, 00864, 00865, 00866, 00868, 00870, 00872, 00873, 00880, 00882]|
|00902-00952||Anesthesia for procedures on perineum [includes codes 00902, 00904, 00906, 00908, 00910, 00912, 00914, 00916, 00918, 00920, 00921, 00922, 00924, 00926, 00928, 00930, 00932, 00934, 00936, 00938, 00940, 00942, 00944, 00948, 00950, 00952]|
|01112-01190||Anesthesia for procedures on pelvis [includes codes 01112, 01120, 01130, 01140, 01150, 01160, 01170, 01173, 01180, 01190]|
|01200-01274||Anesthesia for procedures on upper leg [includes codes 01200, 01202, 01210, 01212, 01214, 01215, 01220, 01230, 01232, 01234, 01250, 01260, 01270, 01272, 01274]|
|01320-01444||Anesthesia for procedures on knee and popliteal area [includes codes 01320, 01340, 01360, 01380, 01382, 01390, 01392, 01400, 01402, 01404, 01420, 01430, 01432, 01440, 01442, 01444]|
|01462-01522||Anesthesia for procedures on lower leg [includes codes 01462, 01464, 01470, 01472, 01474, 01480, 01482, 01484, 01486, 01490, 01500, 01502, 01520, 01522]|
|01610-01682||Anesthesia for procedures on shoulder and axilla [includes codes 01610, 01620, 01622, 01630, 01634, 01636, 01638, 01650, 01652, 01654, 01656, 01670, 01680, 01682]|
|01710-01782||Anesthesia for procedures on upper arm and elbow [includes codes 01710, 01712, 01714, 01716, 01730, 01732, 01740, 01742, 01744, 01756, 01758, 01760, 01770, 01772, 01780, 01782]|
|01810-01860||Anesthesia for procedures on forearm, wrist, and hand [includes codes 01810, 01820, 01829, 01830, 01832, 01840, 01842, 01844, 01850, 01852, 01860]|
|01905-01953||Anesthesia for radiological procedures, burn excisions or debridement [includes codes 01916, 01920, 01922, 01924, 01925, 01926, 01930, 01931, 01932, 01933, 01935, 01936, 01951, 01952, 01953]|
|01958-01969||Anesthesia for obstetric procedures [includes codes 01958, 01960, 01961, 01962, 01963, 01965, 01966, 01967, 01968, 01969]|
|01990-01999||Other anesthesia procedures [includes codes 01990, 01991, 01992, 01996, 01999]|
|62310||Injection(s), of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, includes contrast for localization when performed, epidural or subarachnoid; cervical or thoracic|
|62311||Injection(s), of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, includes contrast for localization when performed, epidural or subarachnoid; lumbar, sacral (caudal)|
|62318||Injection(s), including catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, includes contrast for localization when performed, epidural or subarachnoid; cervical or thoracic|
|62319||Injection(s), including catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, includes contrast for localization when performed, epidural or subarachnoid; lumbar, sacral (caudal)|
|64400-64450||Introduction/injection of anesthetic agent (nerve block), diagnostic or therapeutic [when used for regional anesthesia; includes codes 64400, 64402, 64405, 64408, 64410, 64413, 64415, 64416, 64417, 64418, 64420, 64421, 64425, 64430, 64435, 64445, 64446, 64447, 64448, 64449, 64450]|
|99100||Anesthesia for patient of extreme age, younger than 1 year and older than 70|
|99116||Anesthesia complicated by utilization of total body hypothermia|
|99135||Anesthesia complicated by utilization of controlled hypotension|
|99140||Anesthesia complicated by emergency conditions (specify)|
|99143-99145||Moderate sedation services (other than those services described by codes 00100-01999) provided by the same physician or other qualified healthcare professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status [includes codes 99143, 99144, 99145]|
|99148-99150||Moderate sedation services (other than those services described by codes 00100-01999) provided by a physician or other qualified healthcare professional other than the health care professional performing the diagnostic or therapeutic service that the sedation supports [includes codes 99148, 99149, 99150]|
|CPT Physical Status Modifiers|
|P1||A normal healthy patient (Class I)|
|P2||A patient with mild systemic disease (Class II)|
|P3||A patient with severe systemic disease (Class III)|
|P4||A patient with severe systemic disease that is a constant threat to life (Class IV)|
|P5||A moribund patient who is not expected to survive without the operation (Class V)|
|HCPCS Anesthesia Modifiers|
|AA||Anesthesia services performed personally by anesthesiologist|
|AD||Medical supervision by a physician: more than four concurrent anesthesia procedures|
|G8||Monitored anesthesia care (MAC) for deep complex, complicated, or markedly invasive surgical procedure|
|G9||Monitored anesthesia care for patient who has history of severe cardio-pulmonary condition|
|QK||Medical direction of two, three, or four concurrent anesthesia procedures involving qualified individuals|
|QS||Monitored anesthesia care service|
|QX||CRNA service: with medical direction by a physician|
|QY||Medical direction of one certified registered nurse anesthetist (CRNA) by an anesthesiologist|
|QZ||CRNA service: without medical direction by a physician|
Anesthesia services are provided by or under the supervision of a physician. Services consist of the administration of an anesthetic agent in various types of anesthesia.
Types of Anesthesia and Anesthesia Services
Anesthesia Service by the Surgeon: Anesthesia services personally furnished by the physician performing the surgical, therapeutic or diagnostic procedure are considered an integral component of the primary procedure. This may include local injections, regional blocks, and intravenous medication. General anesthesia administered and monitored by the surgeon is not considered medically appropriate.
Balanced Anesthesia: Anesthesia that uses a combination of drugs, each in an amount sufficient to produce its major or desired effect to the optimum degree and keep its undesirable or unnecessary effects to a minimum.
Bier Block/Bier's Local Anesthesia: Regional anesthesia produced by intravenous injection, used for surgical procedures on the arm below the elbow or the leg below the knee; performed in a bloodless field maintained by a pneumatic tourniquet that also prevents the anesthetic from entering the systemic circulation.
Brachial Plexus Block/Brachial Plexus Anesthesia: Regional anesthesia of the shoulder, arm, and hand by injection of a local anesthetic into the brachial plexus.
Caudal Block/Caudal Anesthesia: Regional anesthesia produced by injection of a local anesthetic into the caudal or sacral canal.
Closed Circuit Anesthesia: Inhalation anesthesia maintained by the continuous rebreathing of a relatively small amount of the anesthetic gas and a basal amount of oxygen, normally used with an absorption apparatus for the removal of carbon dioxide.
Endobronchial Anesthesia: Anesthesia produced by introduction of a gaseous mixture through a slender tube placed in the large bronchus.
Endotracheal Anesthesia: Anesthesia produced by introduction of a gaseous mixture through a wide-bore tube inserted into the trachea through either the mouth or the nose.
Epidural Anesthesia: Regional anesthesia produced by injection of the anesthetic agent between the vertebral spines and beneath the ligamentum flavum into the epidural space.
General Anesthesia: A reversible state of unconsciousness and the inability to perceive pain, produced by anesthetic agents, with absence of pain sensation over the entire body and a greater or lesser degree of muscular relaxation; the drugs producing this state can be administered by inhalation, intravenously, intramuscularly, rectally, or via the gastrointestinal tract.
Hypotensive Anesthesia: Anesthesia accompanied by the deliberate lowering of the blood pressure, a procedure said to reduce blood loss and improve usability of the surgical field.
Hypothermic Anesthesia: Anesthesia accompanied by the deliberate lowering of body temperature.
Inhalation Anesthesia: Anesthesia produced by the inhalation of vapors of a volatile liquid or gaseous anesthetic agent.
Insufflation Anesthesia: Anesthesia produced by blowing a mixture of gases or vapors through a tube introduced into the respiratory tract.
Intercostal Anesthesia: Anesthesia produced by blocking intercostal nerves with a local anesthetic.
Intranasal Anesthesia: Local anesthesia produced by insertion into the nasal fossae of pledgets soaked in a solution of an anesthetic agent which is effective after topical application, or by insufflation of a mixture of anesthetic gases or vapors through a tube introduced into the nose.
Intraoral Anesthesia: Anesthesia produced within the oral cavity by injection, spray, pressure, etc.
Intrathecal Anesthesia: Anesthesia produced by injection of an anesthetic solution into either the subarachnoid or subdural space.
Intravenous Anesthesia: Anesthesia produced by introduction of an anesthetic agent into a vein.
Local Anesthesia: Anesthesia confined to one area of the body.
Moderate ("Conscious") Sedation: Involves the administration of medication with or without analgesia to achieve a state of depressed consciousness while maintaining the individual's ability to respond to stimulation. Moderate ("conscious") sedation is administered by the surgeon or physician performing the procedure or an independent trained practitioner for the purpose of assisting the physician in monitoring the individual's level of consciousness and physiological status. It includes pre- and post-sedation evaluations, administration of the sedation and monitoring of the cardiorespiratory function. Cardiorespiratory functions monitored include heart rate, blood pressure and oxygen level.
Monitored Anesthesia Care (MAC): MAC was developed in response to the shift to providing more surgical and diagnostic services in an ambulatory, outpatient or office setting without the use of the traditional general anesthetic. 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 consciousness altering drugs. This type of anesthesia is referred to as MAC if directly provided by anesthesia personnel. Based on the American Society of Anesthesiologists' (ASA) standards for monitoring, MAC should be provided by qualified anesthesia personnel (anesthesiologists or qualified anesthetists such as certified registered nurse anesthetists). These individuals must be continuously present to monitor and provide anesthesia care.
As described by the ASA's Position on Monitored Anesthesia Care (2013):
Monitored anesthesia care is a specific anesthesia service for a diagnostic or therapeutic procedure. Indications for monitored anesthesia care include the nature of the procedure, the patient's clinical condition or the potential need to convert to a general or regional anesthetic.
Monitored anesthesia care includes all aspects of anesthesia care – a preprocedure visit, intraprocedure care and postprocedure anesthesia management. During monitored anesthesia care, the anesthesiologist provides or medically directs a number of specific services, including but not limited to:
Monitored anesthesia care may include varying levels of sedation, analgesia, and anxiolysis as necessary. The provider of monitored anesthesia care must be prepared and qualified to convert to general anesthesia when necessary. If the patient loses consciousness and the ability to respond purposefully, the anesthesia care is a general anesthetic, irrespective of whether airway instrumentation is required.
Patient-Controlled Analgesia (IV PCA): A method of pain control which allows the individual to control their own dosage of analgesia received. It involves the use of a patient-controlled analgesia (PCA) infusion pump which delivers the desired amount of medication through a conventional intravenous route or via an implantable intravenous catheter inserted in subcutaneous tissue.
Regional Anesthesia: Anesthesia that involves the use of local anesthetic solutions(s) to produce circumscribed areas of loss of sensation. This includes spinal, epidural, nerve, field and extremity blocks. Spinal and epidural anesthesia is produced by injection of local anesthetic solution near the spinal canal, which interrupts sensation from the legs or abdomen.
Sacral Anesthesia: Anesthesia produced by injection of a local anesthetic into the extradural space of the sacral canal.
Saddle Block Anesthesia: A type of sacral anesthesia produced in a region corresponding roughly with the area of the buttocks, perineum, and inner aspects of the thighs, by introducing the anesthetic agent low in the dural sac.
Spinal Anesthesia: 1) Regional anesthesia produced by injection of a local anesthetic into the subarachnoid space around the spinal cord. 2) Loss of sensation due to a spinal lesion.
Standby Anesthesia: Anesthesia standby occurs when the anesthesiologist, or the CRNA, is available in the facility in the event he or she is needed for a procedure that requires anesthesia (e.g., available in the facility in case of obstetric complications - breech presentation, twins, and trial of instrumental delivery), but is not physically present or providing services. Standby anesthesia is not direct care (i.e., it is a standby service without direct hands-on contact).
Surgical Anesthesia: That degree of anesthesia at which pain is completely relieved and surgery may be performed; ordinarily used to designate such depth of general anesthesia.
Topical Anesthesia: Anesthesia produced by application of a local anesthetic directly to the area involved.
American Society of Anesthesiologists Levels of Sedation/Analgesia*
Minimal Sedation (Anxiolysis) is a drug-induced state during which patients respond normally to verbal commands. Although cognitive function and coordination may be impaired, ventilatory and cardiovascular functions are unaffected.
Moderate Sedation/Analgesia ("Conscious Sedation") is a drug-induced depression of consciousness during which patients respond purposefully** to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained.
Deep Sedation/Analgesia is a drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully** following repeated or painful stimulation. The ability to independently maintain ventilatory function may be impaired. Patients may require assistance in maintaining a patent airway, and spontaneous ventilation may be inadequate. Cardiovascular function is usually maintained.
General Anesthesia is a drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation. The ability to independently maintain ventilatory function may be impaired. Patients may require assistance in maintaining a patent airway, and positive pressure ventilation may be required because of depressed spontaneous ventilation or drug-induced depression of neuromuscular function. Cardiovascular function may be impaired.
Because sedation is a continuum, it is not always possible to predict how an individual patient will respond. Hence, practitioners intending to produce a given level of sedation should be able to rescue*** patients whose level of sedation becomes deeper than initially intended. Individuals administering Moderate Sedation/Analgesia ("Conscious Sedation") should be able to rescue*** patients who enter a state of Deep Sedation/Analgesia, while those administering Deep Sedation/Analgesia should be able to rescue*** patients who enter a state of General Anesthesia.
*Monitored Anesthesia Care does not describe the continuum of depth of sedation, rather it describes "a specific anesthesia service in which an anesthesiologist has been requested to participate in the care of a patient undergoing a diagnostic or therapeutic procedure."
**Reflex withdrawal from a painful stimulus is NOT considered a purposeful response.
***Rescue of a patient from a deeper level of sedation than intended is an intervention by a practitioner proficient in airway management and advanced life support. The qualified practitioner corrects adverse physiologic consequences of the deeper-than-intended level of sedation (such as hypoventilation, hypoxia and hypotension) and returns the patient to the originally intended level of sedation. It is not appropriate to continue the procedure at an unintended level of sedation.
Government Agency, Medical Society, and Other Authoritative Publications:
Monitored Anesthesia Care (MAC)
|01/01/2016||Updated Coding section with 01/01/2016 CPT changes, removed 64412 deleted 12/31/2015; also removed ICD-9 codes.|
|Reviewed||05/07/2015||Medical Policy & Technology Assessment Committee (MPTAC) review. Description, Discussion and Reference sections updated.|
|01/01/2015||Updated Coding section with 01/01/2015 CPT changes; removed 00452, 00622, 00634 deleted 12/31/2014.|
|Reviewed||05/15/2014||MPTAC review. Reference section updated.|
|Reviewed||05/09/2013||MPTAC review. References updated.|
|Reviewed||05/10/2012||MPTAC review. References updated.|
|Reviewed||05/19/2011||MPTAC review. References updated.|
|Reviewed||05/13/2010||MPTAC review. Discussion and references updated.|
|01/01/2010||Updated coding section with 01/01/2010 CPT changes; removed CPT 01632 deleted 12/31/2009.|
|Reviewed||05/21/2009||MPTAC review. Discussion, coding and references updated. Place of service section removed.|
|Revised||05/15/2008||MPTAC review. Added a statement for when anesthesia services are not medically necessary. References and appendix updated. Coding updated with 01/01/2008 CPT updates; removed CPT 01905 deleted 12/31/2007.|
|Reviewed||05/17/2007||MPTAC review. References updated.|
|Revised||06/08/2006||MPTAC review. Document title revised. Term conscious sedation updated to moderate sedation per ASA guidelines. Updated definition of MAC per ASA guidelines. Indications for anesthesia services during gastrointestinal endoscopic procedures removed. References updated.|
|Revised||03/23/2006||MPTAC review. Updated language for regional anesthesia. Revision per recommendation from American Society of Anesthesiologists.|
|01/01/2006||Updated coding section with 01/01/2006 CPT/HCPCS changes.|
|Revised||09/22/2005||MPTAC review. Revision based Pre-merger Anthem and Pre-merger WellPoint Harmonization.|
Last Review Date
|WellPoint Health Networks, Inc.|
American Society of Anesthesiology Physical Status Classifications:
ASA I A normal healthy patient
ASA II A patient with mild systemic disease
ASA III A patient with severe systemic disease
ASA IV A patient with severe systemic disease that is a constant threat to life
ASA V A moribund patient who is not expected to survive without the operation
ASA VI A declared brain-dead patient whose organs are being removed for donor purposes