March 8, 2021

Learning the etymology behind certain phrases and words can be most enlightening.  Studying the development of, and relationship between, certain words in the English language, or any other language, can assist us in better overall comprehension.  Take the phrase, “‘a la mode,” for example.  In American English, that phrase has come to mean “with ice cream.”  Originally, however, it was a French phrase roughly meaning “in the fashion of” or simply “in fashion.”  It is not surprising, then, that the English word “mode,” might be defined as something akin to form or fashion.  So, when looking at the title of today’s article, the focus is not on flavorful dessert toppings—as delightful as that would be—but rather on the form and fashion of the anesthesia service.  Today, we’re discussing the mode of anesthesia.

Another way in which the anesthesia mode is often styled—especially on the anesthesia record—is “anesthesia technique.”  For our purposes herein, these are seen as synonymous terms; and, of course, what we mean by these terms is the type of anesthesia service being delivered to the patient.  The reason this topic is relevant is because one of the items a provider is required to document on the anesthesia record is the mode of anesthesia.  In addition, there are important clinical and coding implications tied to the indications you make in this regard, which we will explore a bit later. 

The Big Three

From a billing and compliance perspective, there are only three anesthesia modes—not four or five—and they are as follows: general, regional and monitored anesthesia care (MAC).  We will discuss these three in more detail in a moment; but, at this point, we need to clarify what is not considered an anesthesia mode, at least from a billing perspective.

Despite what some providers may presume, total intravenous anesthesia (TIVA) is not an anesthesia mode, but rather the mechanism by which an anesthetic is delivered.  Typically, one thinks of TIVA only in terms of a general, but we have occasionally seen the term used by some providers in connection with both regional anesthesia and MAC.  As one anesthesia provider recently blogged: “Honestly, you could ask 10 CRNAs or anesthesiologists to define general anesthesia, MAC, TIVA, etc., and get 20 answers.”  So, some providers may occasionally use TIVA to refer to something other than a general.

Because of the potential for confusion, it is best to document the anesthesia mode as either general, regional or MAC, rather than TIVA.  It’s certainly fine to additionally specify TIVA, when applicable, for clinical purposes as part of your anesthesia record documentation—again, as long as you are also documenting one of “the big 3.”  Alternatively, if you are an ABC/Medac client and your providers at a certain facility always mean “general,” for example, when indicating “TIVA” on the anesthesia record, your group president or administrator may send us a written communication to that effect.  Our staff will equate the two terms going forward until otherwise instructed. 

Why Mode Matters

As to the officially recognized modes of anesthesia, we would like to point out the following important factors for your consideration:

Regional Anesthesia.  When documenting a regional block, it is important for you to provide some specificity as to the type and location of the block.  For example, if it involves a continuous lumbar epidural, those are additional details that would prove helpful—especially if you submit charges for rounding on the days subsequent to surgery.  In addition, knowing full details of the regional block or blocks may prove helpful for determining what may and may not be billed relative to post-op pain procedures.

General Anesthesia.  The American Society of Anesthesiologists (ASA) has defined a general as occurring when the patient loses consciousness or the ability to purposefully respond—for any portion of the case.  It matters not whether the patient is intubated.  All this becomes important as we move into a discussion of the next anesthesia mode: MAC.

Monitored Anesthesia Care.  Many providers may not realize that MAC was created as a mode to facilitate payment for what used to be called “standby anesthesia.”  A surgeon would ask that you stand by in the event a patient needed to be put under.  However, most payers provided no reimbursement for this service.  (In 2013, a new code was added for “physician standby services,” but this will rarely apply to anesthesia, as it requires at least 30 minutes of non-patient contact time, during which you cannot be involved in any other case.  In addition, few, if any, payers reimburse it.)

Years ago, we interviewed a member of the ASA’s Committee on Economics who was a driving force for creating a methodology for getting these standby services paid.  The solution: monitored anesthesia care—with the key word being “monitored,” not “anesthesia.”  That is, the anesthesia provider would now be paid for monitoring a patient whose condition and case type might necessitate the eventual performance of a general anesthetic.  However, to obtain payment, the provider would need to perform a pre-anesthesia assessment, complete an anesthesia record, monitor vitals, and perform any indicated post-anesthesia care.  No “anesthesia” need be administered.  The service was about the monitoring, not the drugs.

Today, MAC has evolved in practice to typically incorporate the administration of some type of sedation drug or narcotic.  In other words, even though such drugs are not required to bill a MAC, the vast majority of MAC cases today do, in fact, involve them.  For a large portion of these MAC cases that involve drugs, propofol is the drug of choice.  When propofol is used, it very often leads to the patient losing consciousness.  What all this comes down to is this: a large percentage of cases that are planned as MAC actually become general anesthesia cases intraoperatively.  What are the implications of this?

1. From a coding perspective, certain payers require that we append a QS modifier to the anesthesia code on the claim form when the service is a MAC.  So, if a case that was planned as a MAC ends up being a general, you need to make sure that your documentation reflects “general,” so that we do not errantly list the MAC modifier. 
    
2. From a reimbursement perspective, it might be a mixed bag.  While there is no difference in the level of payment for a particular service based on whether the mode is general or MAC, there is sometimes a difference in whether there is payment at all.  It is a fact that some payers have reimbursed a particular case type if under a general, but not MAC.  More recently, some of these payers have revised their policies so that the requirements for payment, whether under general or MAC, have aligned.  That is, if the patient doesn’t have one of a certain set of comorbidities or conditions relative to certain case types, the payer will not provide reimbursement—regardless of whether the case was under general or MAC.

In a future alert, we will explore the principles of billing and documenting when combined anesthetics are in play.  For now, we will conclude by saying that correctly listing the details of the anesthesia mode is critical to the proper submission of claims.  Providers are therefore encouraged to be as accurate as possible in their anesthesia mode indications.  The anesthesia mode will never be assumed by your documentation of drugs or equipment; so, again, we ask that you clearly specify one of the three modes.  If you have questions about this topic, please reach out to your account executive or email us at info@anesthesiallc.com.

With best wishes,

Tony Mira
President and CEO