G9654 — Monitored anesthesia care (mac)
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
- Documentation of patient's age (≥ 18 years) on date of service.
- Documentation of the interventional pain procedure (procedure note and appropriate CPT/HCPCS code) demonstrating the procedure is one of those covered by this policy when used to justify sedation/MAC (e.g., epidural steroid injection, epidural blood patch, facet joint injection, peripheral/spinal nerve root block, sacroiliac joint injection, or procedures requiring prolonged immobility/painful position such as radiofrequency ablation, spinal cord stimulator implantation, intrathecal device implantation).
- Clinical documentation supporting the specific rationale for moderate sedation or MAC: either (a) objective documentation that the procedure requires the patient to remain motionless for a prolonged period or remain in a painful position, or (b) for the procedure-plus-risk pathway, documentation that the procedure is one of the listed procedures AND documentation of the specific risk factor(s)/comorbidity(ies) that justify MAC (see list of comorbidities).
Key Coverage Criteria
- Moderate sedation (age 18 or over) is medically necessary when the interventional pain procedure requires the individual to remain motionless for a prolonged period of time or in a painful position (examples: sympathetic blocks, plexus blocks, radiofrequency ablation procedures, implantation of spinal cord stimulator, implantation of an intrathecal infusion device).
- Moderate sedation (age 18 or over) is medically necessary when BOTH of the following are met: (a) the procedure being performed is ANY of: epidural steroid injection, epidural blood patch, facet joint injection, peripheral and/or spinal nerve root block, sacroiliac joint injection; AND (b) severe anxiety under active medical management with psychotropic medication and/or cognitive therapy, or other severe psychiatric condition(s), or severe cognitive impairment(s) that would risk endangering the [...]
- Monitored anesthesia care (MAC), including use of general anesthesia (intravenous anesthetic without a secured airway), (age 18 or over) is medically necessary when the interventional pain procedure requires the individual to remain motionless for a prolonged period of time or in a painful position (examples: sympathetic blocks, plexus blocks, radiofrequency ablation procedures, implantation of spinal cord stimulator, implantation of an intrathecal infusion device).
- Monitored anesthesia care (MAC) (age 18 or over) is medically necessary when BOTH of the following are met: (a) the procedure being performed is ANY of: epidural steroid injection, epidural blood patch, facet joint injection, peripheral and/or spinal nerve root block, sacroiliac joint injection; AND (b) presence of ANY of the following risk factors/comorbidities that increase risk for complications: ASA physical status III or above; severe cardiac disease and/or pulmonary disease (e.g., severe h [...]
- Interventional pain management procedures (general scope covered by this policy for adults) include: trigger point injections; epidural steroid injection; epidural blood patch; facet joint injection; peripheral and/or spinal nerve root block; sacroiliac and other joint injection (e.g., knee, shoulder, hip); radiofrequency ablation; implantation of spinal cord stimulator; implantation of an intrathecal infusion device. [...]
- Billing/coding: Moderate sedation CPT codes (99152, 99153, 99156, 99157) are considered medically necessary when moderate sedation criteria are met; MAC/anesthesia CPT/HCPCS codes (e.g., 01937-01942, 01991-01992, G9654) are considered medically necessary when MAC criteria are met.
1 Active Policy
CIGNA-0551 — Anesthesia Services for Interventional Pain Management Procedures in an Adult - (0551)
Related Codes
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