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Anesthesia & Pain Management

Anesthesia is the administration of a drug or gas to induce partial or complete loss of consciousness. Services involving administration of anesthesia should be reported by the use of the CPT anesthesia five-digit procedure code plus modifier codes. Surgery codes are not appropriate unless the anesthesiologist or Qualified Nonphysician Anesthetist is performing the surgical procedure.

Access the below anesthesia and pain management related information from this page.

General Anesthesia Guidelines

Anesthesia services include (but not limited to) local, general or regional

  • By a physician/anesthesiologist under medical supervision of a physician
  • CRNA or AA may also provide services - Locum tenens do not apply to CRNA / AA

Services include

  • Pre/post-operative visits
  • Anesthesia care during the procedure
  • Administration of fluids and/or blood
  • Usual monitoring service - E.g., ECG, temperature, blood pressure, oximetry, capnography and mass spectrometry

Separate/multiple anesthesia procedures performed during single anesthetic administration

  • Most complex procedure reported
  • Combine time for all procedures

Epidural injections/other forms of nerve blockade reimbursed (as part of anesthetic management), when used as primary anesthesia route or obstetrical analgesia

Monitored Anesthesia Care (MAC)

Monitored anesthesia care (MAC) includes the monitoring of the patient by a practitioner who is qualified to administer anesthesia as defined by the regulations at 42 CFR 482.52(a) This link takes you to an external website..  Indications for MAC depend on the nature of the procedure, the patient's clinical condition and/or the potential need to convert to a general or regional anesthetic for a diagnostic or therapeutic procedure. Deep sedation/analgesia is included in MAC.

Indications and Limitations of Coverage and/or Medical Necessity

  • 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 (CRNA) or anesthesia assistants (AA)]. 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 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.
  • 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.
  • The MAC service rendered must be appropriate and medically reasonable and necessary.

Modifiers used for MAC

  • QS - Appended with appropriate ICD-9-CM code for co-existing condition(s). This is placed in second modifier field: pricing anesthesia modifier is place in first modifier field
  • G8 - Indicates surgical procedure is deep, complex, complicated or markedly invasive
  • G9 - Appended with an anesthesia code to indicate that patient has a history of a severe cardiopulmonary condition

Medical record should include:

  • Clear indication of patient name, date of birth and date of service
  • Documentation must support diagnosis code billed
  • Include documentation of pre anesthetic exam and evaluation
  • Include intra-operative report with documentation of anesthesia time
  • A complete operative report
  • Post anesthesia report
  • Documentation shows beginning of services, any time spent away from patient, and discontinuance of services
  • Medical records clearly show number of concurrent services being supervised by physician or CRNA

Resources

Last Updated Jul 26, 2017

The below are topic specific articles which have been published to "Latest Updates" and sent out in Noridian emails within the past two years. Exclusions to this include time sensitive related announcements such as: Noridian and CMS educational events, Ask-the-Contractor Teleconferences and claims processing downtime.