Medicare billing and MAC

[powermd]

My partners and I are having a discussion about MDC requirements to bill MAC and have found that statements made in Medicare documents are difficult to interpret clearly.

We do MAC for our in-office kyphoplasty procedures in combination with an epidural anesthetic. We have not been monitoring ETCO2, or temp, but we do use all other ASA standard monitors. We typically sedate with midazolam in the moderate to deep range.

We have the following questions:

1. Is deep sedation required to bill MAC for MDC patients?
2. Is ETCO2 monitoring REQUIRED to bill MAC for MDC patients?

Here are some relevant statements from the ASA and from Medicare:

The ASA defines MAC as follows:

"Monitored Anesthesia Care (“MAC”) 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.”

Source: https://www.asahq.org/For-Members/~.../2015/Continuum of Depth of Sedation 2014.pdf

The ASA seems to set a standard of ETCO2 monitoring for moderate or deep sedation, with a loophole in the last sentence leaving it all open to individual circumstances.

"3.2.4 During regional anesthesia (with no sedation) or local anesthesia (with no
sedation), the adequacy of ventilation shall be evaluated by continual observation
of qualitative clinical signs. During moderate or deep sedation the adequacy of
ventilation shall be evaluated by continual observation of qualitative clinical signs
and monitoring for the presence of exhaled carbon dioxide unless precluded or
invalidated by the nature of the patient, procedure, or equipment. "

Source: https://www.asahq.org/For-Members/~...s Stmts/Basic Anesthetic Monitoring 2011.ashx

According to this document, Medicare defines MAC as follows, consistent with the ASA definition:

"Monitored anesthesia care involves the intra-operative monitoring by a physician or qualified individual under the medical direction of a physician or of the patient’s vital physiological signs in anticipation of the need for administration of general anesthesia or of the development of adverse physiological patient reaction to the surgical procedure."

Source: http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf

Here is where things get confusing:

CMS Manual 100-07 Clarification of the Interpretive Guidelines for the Anesthesia Services Condition of Participation

• Monitored Anesthesia Care (MAC): anesthesia care that includes the monitoring of the patient by a practitioner who is qualified to administer anesthesia as defined by the regulations at §482.52(a). 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. Deep sedation/analgesia is included in MAC.
  

The next section goes on to state very specifically that moderate sedation is NOT anesthesia.

One could interpret this as follows: If moderate sedation is NOT anesthesia, Medicare therefore requires that the patient receive deep sedation in order for anesthesia to have occurred, and thus for MAC to be billed. This interpretation seems correct, and one of my partners is convinced of this, but it flies in the face of the ASA definition of MAC which specifically says it does not describe the continuum of depth of sedation.

Another interpretation (mine) hinges on the fact that Medicare uses the word "included" but not "required" when describing deep sedation in relation to MAC. Deep sedation may be a part of MAC, but does not define MAC. Moderate sedation may therefor be MAC if an anesthesiologist was requested to be present and monitor the patient throughout the procedure, ready to deepen anesthesia as needed.

With respect to ETCO2 monitoring, no where does CMS specifically lay out a prescription for required monitors, they do say:

"Delivery of anesthesia services consistent with recognized standards for anesthesia care."

This sounds like they are deferring to the ASA on this.

The question becomes would an auditor retroactively deny payment for all your MAC cases if they found you had not been monitoring ETCO2 based on the ASA statement, which is specific on capnography for deep sedation, and yet vague on loopholes.

I know, we all need to get a freakin' life!

I have already conceded that it would be reasonable to invest the 2k in a capnography capable monitor, but we'd still like to figure out who's right.

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[powermd]

We do have two providers present, we are all BC anesthesiologists in the group. Sometimes we basically flip a coin to figure out who does the procedure and who sedates. The proceduralist does the epidural out of convenience (he's in the field), but I'm not sure it's even necessary. I've done a number of cases with local on the pedicles only and the patient is no more reactive to stimuli. The major anesthetic is the IV sedation, which, being that it is titrated moment to moment by a dedicated anesthesiologist, should constitute MAC.

The real questions here are medicolegal with respect to what Medicare believes. We have emailed the ASA for feedback. I'll post their response.

 

[lynchmd]

Keep in mind that the answer is dependent on which state you are in, as Medicare policies are regionally operated. Here is my answer for Arizona. While each state and LCD is generally slightly different the concept that we must observe Oxygenation, Ventilation, Circulation and Temperature seems to be fairly consistent from state to state. I would argue that the mechanism of observing the ventilation portion is at the discretion of the Anesthesiologist.


This is pulled from LCD L24332 (Arizona MAC LCD)

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-9-CM code list. In this situation, the appropriate MAC modifier is QS, which should be billed along with the appropriate ICD-9-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 (00100 and 00160); head, neck, and posterior trunk (00300); breast (00400), or genitalia (00920) and for access to the central venous circulation (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.

6. 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.

7. The presence of an underlying condition alone, as reported by an ICD-9-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.