Monitored Anesthesia Care:
Does Your Carrier Use the New Medicare Modifiers?
Published on Mon Nov 01, 1999
Anesthesia care often involves administering medication in dosages that cause the patient to lose normal protective reflexes or that may lead to a loss of consciousness. Monitored anesthesia care (MAC), is the term used to describe situations when the patient remains able to protect his or her airway for the majority of the procedure, usually a diagnostic or therapeutic procedure such as a breast biopsy or colonoscopy. In this situation, an anesthesiologist may be requested to participate in the procedure in case the patient is ren-
dered unconscious and/or loses normal protective reflexes for an extended period of time.
A number of services are provided during MAC. These can include monitoring vital signs and maintaining the patients airway; diagnosing and treating clinical problems during the procedure, administering medications as necessary to ensure the patients safety and comfort, and providing other medical services as needed to safely complete the procedure.
Monitored anesthesia care is a physician service offered to an individual patient based on medical necessity, says Mike Scott, director of governmental and legal affairs at the American Society of Anesthesiologists (ASA). It should be reimbursed at the same level as general or regional anesthesia.
However, many Medicare carriers use a medical necessity policy that rejects claims for MAC for certain procedures, Scott says. For example, these carriers wont pay for codes 00100 (integumentary system of head and/or salivary glands, including biopsy) or 00400 (anterior integumentary system of chest, including subcutaneous tissue) unless a particular ICD-9 diagnostic code that supports medical necessity is also applied.
This non-reimbursement policy has been controversial for some carriers, because if a carrier doesnt reimburse for MAC procedures that fall under codes 00100 or 00400, women could theoretically undergo breast biopsies or other procedures covered by these codes without anesthesia. Codes 00100 and 00400 cover numerous procedures, some of which are truly minor and dont need MAC, says Karin Bierstein, ASAs practice management coordinator. But other procedures covered by those same codes should have anesthesia. Many carriers that initially adopted the rejection policy have reversed themselves or accepted modifications; most Medicare intermediaries should have a list of payable diagnoses for MAC that coders can use as a guide.
Putting New Modifiers in Place
The American Society of Anesthesiologists worked with the medical directors of the carriers that were still rejecting claims to come to an agreement on what would be acceptable to both parties, Scott continues. Our discussions led to HCFA sending a program memorandum to all carriers last spring that gives carriers the option of using two new modifiers that would indicate that MAC should [...]
