Anesthesia Coding Alert

Question: How should I code for monitored anesthesia care (MAC) during a colonoscopy? Our Medicare carrier has a MAC medical policy and the anesthesia code of 00810 (anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum) is on the Category B list, which states that anesthesia is not usually needed or should be a administered as local anesthetic by the surgeon.

New York Subscriber
Answer: Many carriers will not reimburse for MAC with these types of procedures, but there are a few that will. The most important thing to remember is that there should always be a medical reason for using anesthesia during these procedures, not just patient comfort, and that this medical necessity must be documented. Most carriers have very specific diagnoses that warrant MAC, or other requirements that must be met for reimbursement. For example, the Medicare carrier in Ohio states that the patient must have a P3 (a patient with severe systemic disease) or higher physical status unless the diagnosis code supports medical necessity in patients with a lower status. A commonly accepted diagnosis is V58.83 (encounter for therapeutic drug monitoring) when the anesthesiologist uses propofol (Diprivan). If the procedure is not covered, an advance beneficiary notice (ABN) should be obtained with the patient stating he or she is financially responsible for the anesthesia. The claim is then filed with modifiers as appropriate: -QS (monitored anesthesia care service), -GA (waiver of liability statement on file), -GY (non-covered service) or -GZ (not a Medicare benefit).
Reader Questions and You Be the Coder answered by Barbara Newberry, CPC, coding manager with the physician group Watchcare Anesthesia Inc., in Berryville, Ark.