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POLICY – MPP – 192 Anesthesia Services and Moderate (“Conscious”)SedationDepartment/TeamMedical Management/Medical Payment Policy (MPP)Approval ByHQUMApproval Date09/25/2020Effective Date05/02/2011Line of Business CCC Medallion 4.0 D-SNP MAPD ExchangePURPOSEThis policy outlines guidelines and criteria for coverage determination of anesthesia services and moderate(“conscious”) sedation.DESCRIPTIONConscious sedation, produced by the administration of certain medications, is an altered level of consciousnessthat still allows a patient to respond to physical stimulation and verbal commands, and to maintain anunassisted airway. The purpose of conscious sedation is to produce a state of relaxation and/or pain relief byusing benzodiazepine-type and narcotic medications, to facilitate performing a procedure such as a biopsy,radiologic imaging study, endoscopic procedure, radiation therapy, or bone marrow aspiration.GUIDELINES/INSTRUCTIONSSCOPE: This policy specifically addresses the medical necessity of anesthesia services.POSITION:Medically Necessary:General Anesthesia or Regional AnesthesiaAdministration of general or regional anesthesia is considered medically necessary when both of the followingcriteria are met:a. The services are provided by an individual other than the attending physician performing the procedure; ANDb. Alternative types of anesthesia, sedation, or analgesia are not appropriate.If general or regional anesthesia is requested for a procedure typically not requiring either of these levels ofanesthesia service, a medical necessity review will be performed. This review will assess not only the procedureinvolved, but also other patient-specific issues, such as age, mental status, ability to cooperate, co-morbidconditions, and general medical status.Monitored Anesthesia Care (MAC)Monitored anesthesia care (MAC) is considered medically necessary when all of the following criteria are met:Page 1 of 7

POLICY – MPP – 192 Anesthesia Services and Moderate (“Conscious”)Sedationa. MAC is requested by the attending physician; ANDb. The services are provided by an individual other than the attending physician performing the procedure; ANDc. Qualified anesthesia personnel (anesthesiologists or qualified anesthetists such as certified registered nurseanesthetists) administering monitored anesthesia care are continuously present to monitor the patient andprovide anesthesia care; ANDd. The patient's medical condition requires medical direction or supervision of the anesthetic to ensure control ofthe sedation, medication, and airway, and to prevent sudden changes in condition from disrupting theprocedure and placing the patient at risk; ANDe. Constant monitoring of the patient's vital signs is provided to anticipate the need for general anesthesiaadministration 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 proceduremay become more extensive, or result in unforeseen complications, requires comprehensive monitoring oranesthetic intervention; ANDf. Appropriate documentation is available to reflect pre- and post-anesthetic evaluations and intraoperativemonitoring.Anesthesia Services including MACFor surgical procedures which do not usually require anesthesia services, anesthesia services includingmonitored anesthesia care (MAC) are considered medically necessary when the patient's condition requiresthe presence of qualified anesthesia personnel to perform monitored anesthesia in addition to the physicianperforming the procedure, and is so documented. The medical condition must be significant enough to impactthe need to provide anesthesia services including MAC. Complex procedures and procedures in high-riskpatients may justify the use of an anesthesiologist or anesthetist to provide conscious sedation or deepsedation. See Appendix for physical status classifications. The presence of a stable, treated condition of itself isnot necessarily sufficient.Moderate ("Conscious") SedationModerate sedation ("conscious sedation") ordered by the attending physician and administered by the surgeonor physician performing the procedure or an independent trained practitioner is considered medicallynecessary when alternative types of anesthesia, sedation, or analgesia are not appropriate.Local AnesthesiaThe administration of local anesthesia is considered medically necessary when alternative types of anesthesia,sedation, or analgesia are not appropriate.Standby Anesthesia ServicesStandby anesthesia service is when the anesthesiologist would be immediately available if a clinical needshould arise but the anesthesiologist may be elsewhere performing other duties. Stand-by anesthesia isconsidered medically necessary when a procedure, which does not normally require anesthesia services, has asignificant potential for catastrophic complications or potential for the need of other intervention that wouldrequire immediate availability of general anesthesia.Not Medically Necessary:Anesthesia services are considered not medically necessary for all other indications.CODING:CPTPage 2 of 7

POLICY – MPP – 192 Anesthesia Services and Moderate (“Conscious”)Sedation00100-00222Anesthesia 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]00300-00352Anesthesia for procedures on the neck [includes codes 00300, 00320, 00322, 00326, 00350, 00352]00400-00474Anesthesia for procedures on the thorax [includes codes 00400, 00402, 00404, 00406, 00410, 00450, 00452,00454, 00470, 00472, 00474]00500-00580Anesthesia 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]00600-00670Anesthesia for procedures on spine and spinal cord [includes codes 00600, 00604, 00620, 00622, 00625, 00626,00630, 00632, 00634, 00635, 00640, 00670]00700-00797Anesthesia for procedures on upper abdomen [includes codes 00700, 00702, 00730, 00750, 00752, 00754,00756, 00770, 00790, 00792, 00794, 00796, 00797]00800-00882Anesthesia 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]00902-00952Anesthesia 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]01112-01190Anesthesia for procedures on pelvis [includes codes 01112, 01120, 01130, 01140, 01150, 01160, 01170, 01173,01180, 01190]01200-01274Anesthesia for procedures on upper leg [includes codes 01200, 01202, 01210, 01212, 01214, 01215, 01220,01230, 01232, 01234, 01250, 01260, 01270, 01272, 01274]01320-01444Anesthesia 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]01462-01522Anesthesia for procedures on lower leg [includes codes 01462, 01464, 01470, 01472, 01474, 01480, 01482,01484, 01486, 001490, 01500, 01502, 01520, 01522]Page 3 of 7

POLICY – MPP – 192 Anesthesia Services and Moderate (“Conscious”)Sedation01610-01682Anesthesia for procedures on shoulder and axilla [includes codes 01610, 01620, 01622, 01630, 01634, 01636,01638, 01650, 01652, 01654, 01656, 01670, 01680, 01682]01710-01782Anesthesia 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]01810-01860Anesthesia for procedures on forearm, wrist, and hand [includes codes 01810, 01820, 01829, 01830, 01832,01840, 01842, 01844, 01850, 01852, 01860]01905-01953Anesthesia for radiological procedures, burn excisions or debridement [includes codes 01916, 01920, 01922,01924, 01925, 01926, 01930, 01931, 01932, 01933, 01935, 01936, 01951, 01952, 01953]01958-01969Anesthesia for obstetric procedures [includes codes 01958, 01960, 01961, 01962, 01963, 01965, 01966, 01967,01968, 01969]01990-01999Other anesthesia procedures [includes codes 01990, 01991, 01992, 01996, 01999]62310Injection, single (not via indwelling catheter), not including neurolytic substances, with or without contrast (foreither localization or epidurography), of diagnostic or therapeutic substance(s) (including anesthetic,antispasmodic, opioid, steroid, other solution), epidural or subarachnoid; cervical or thoracic62311Injection, single (not via indwelling catheter), not including neurolytic substances, with or without contrast (foreither localization or epidurography), of diagnostic or therapeutic substance(s) (including anesthetic,antispasmodic, opioid, steroid, other solution), epidural or subarachnoid; lumbar, sacral (caudal)62318Injection, including catheter placement, continuous infusion or intermittent bolus, not including neurolyticsubstances, with or without contrast (for either localization or epidurography), of diagnostic or therapeuticsubstance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), epidural or subarachnoid;cervical or thoracic62319Injection, including catheter placement, continuous infusion or intermittent bolus, not including neurolyticsubstances, with or without contrast (for either localization or epidurography), of diagnostic or therapeuticsubstance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), epidural or subarachnoid;lumbar, sacral (caudal)64400-64450Introduction/injection of anesthetic agent (nerve block), diagnostic or therapeutic [when used for regionalanesthesia; includes codes 64400, 64402, 64405, 64408, 64410, 64412, 64413, 64415, 64416, 64417, 64418,64420, 64421, 64425, 64430, 64435, 64445, 64446, 64447, 64448, 64449, 64450]Page 4 of 7

POLICY – MPP – 192 Anesthesia Services and Moderate (“Conscious”)Sedation99100Anesthesia for patient of extreme age, under 1 year and over 7099116Anesthesia complicated by utilization of total body hypothermia99135Anesthesia complicated by utilization of controlled hypotension99140Anesthesia complicated by emergency conditions (specify)99143-99145Moderate sedation services (other than those services described by codes 00100-01999) provided by the samephysician performing the diagnostic or therapeutic service that the sedation supports, requiring the presenceof an independent trained observer to assist in the monitoring of the patient's level of consciousness andphysiological status [includes codes 99143, 99144, 99145]99148-99150Moderate sedation services (other than those services described by codes 00100-01999) provided by aphysician other than the health care professional performing the diagnostic or therapeutic service that thesedation supports [includes codes 99148, 99149, 99150]CPT Physical Status ModifiersP1A normal healthy patient (Class I)P2A patient with mild systemic disease (Class II)P3A patient with severe systemic disease (Class III)P4A patient with severe systemic disease that is a constant threat to life (Class IV)P5A moribund patient who is not expected to survive without the operation (Class V)HCPCSHCPCS Anesthesia ModifiersAAAnesthesia services performed personally by anesthesiologistADMedical supervision by a physician: more than four concurrent anesthesia proceduresPage 5 of 7

POLICY – MPP – 192 Anesthesia Services and Moderate (“Conscious”)SedationG8Monitored anesthesia care (MAC) for deep complex, complicated, or markedly invasive surgical procedureG9Monitored anesthesia care (MAC) for patient who has history of severe cardio-pulmonary conditionQKMedical direction of two, three, or four concurrent anesthesia procedures involving qualified individualsQSMonitored anesthesia care (MAC) serviceQXCRNA service: with medical direction by a physicianQYMedical direction of one certified registered nurse anesthetist (CRNA) by an anesthesiologistQZCRNA service: without medical direction by a physicianICD-10 DiagnosisAll DiagnosesREFERENCES1. e/guidelines/gl pw a050123.html AccessedSeptember 13, 2020Government Agency, Medical Society, and Other Authoritative Publications1. ASA Physical Status Classification System. Available at: hysical-status-classification-system.pdf September 13, 20202. American Society of Anesthesiologists. Position on Monitored Anesthesia /position-on-monitored-anesthesia-care.pdf Accessed September13, 20203. American Society of Anesthesiologists. Distinguishing Monitored Anesthesia care (“MAC”) From ModerateSedation/Anesthesia (Conscious Sedation). rate-sedationanalgesia-conscious-sedation Accessed September13, 2020Related DocumentsPage 6 of 7

POLICY – MPP – 192 Anesthesia Services and Moderate yDr. Tamar SpringelDr. Tamar SpringelRevision HistoryDescriptionAnnual reviewPage 7 of 7