01130
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- All documentation supporting MAC must be maintained in the patient's medical record, be legible, include complete patient identification and dates of service, and be made available to the contractor upon request.
- The medical record must include the legible signature of the physician or non-physician practitioner responsible for and providing the care.
- The submitted medical record must support the selected ICD-10-CM code(s) and the submitted CPT/HCPCS code must accurately describe the service performed.
- When G9 modifier is used for history of severe cardiopulmonary disease, document the clinical decision-making process and the need for additional monitoring in the medical record.
Key Coverage Criteria
- Monitored Anesthesia Care (MAC) is medically necessary when the patient has one or more documented diagnoses listed as supporting medical necessity (e.g., F91.9, G97.81, T81.9XXA, T88.8XXA, F79) and the diagnosis is matched to the anesthesia/CPT/HCPCS procedure performed.
- Use G9 anesthesia modifier to indicate need for MAC due to a history of severe or advanced cardiopulmonary disease when the proceduralist determines additional monitoring is required.
- Use G8 anesthesia modifier for certain deep, complex, complicated, or markedly invasive surgical procedures when applied to anesthesia codes 00100, 00300, 00400, 00160, 00532, or 00920.
- MAC may be appropriate for pediatric patients (Medicare-eligible and younger than 18) when documented using ICD-10-CM code T88.8XXA and clinical records justify the need for MAC.
- Monitored anesthesia care (MAC) is covered when provided by qualified anesthesia personnel who are continuously present to monitor the patient and provide anesthesia care in accordance with state licensure.
- MAC is covered when the patient requires active monitoring of oxygenation, ventilation, circulation, or temperature during the procedure, using appropriate methods (e.g., pulse oximetry, capnography) as determined by the attending anesthetist.
3 Active Policies
A57361 — Billing and Coding: Monitored Anesthesia Care
J12
L35049 — Monitored Anesthesia Care
J12
ANTHEM-CG-MED-21 — CG-MED-21 Anesthesia Services and Moderate (âConsciousâ) Sedation
Related Codes
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