The Big MAC: Sizing Up Monitored Anesthesia Care
Summary: When the anesthesia provider opts for monitored anesthesia care in a patient case, what is he/she really signing on to? This anesthesia technique is a bit slippery in terms of identification, requirements and even payment.
Several months ago, we published an article on the three anesthesia techniques available to anesthesiologists and anesthetists from a documentation and billing perspective. Today's article focuses particular attention on the third of those techniques: monitored anesthesia care (MAC). Unlike general and regional anesthesia, MAC comes with a unique set of nuances for providers to consider. To be more direct, there are potential pitfalls in getting paid unless certain patient circumstances are in play and successfully documented. MAC is not a slam dunk.
Because there are a number of requirements surrounding the use and submission of MAC, it may be helpful for our readers to see what the authoritative sources actually say about this anesthesia technique. Accordingly, our purpose for this article is to supply examples of payer and other policy language that will allow the anesthesia provider to have a better appreciation of what MAC is and is not, when it can be used, and how to get it paid.
Pinning It Down
The first thing to understand about this technique is that MAC is primarily about monitoring rather than sedation. You are monitoring in order to determine if the patient needs to be placed under a general (or perhaps a regional) anesthetic. Indeed, there is no requirement for any drug, sedation or anesthetic in a MAC case. That remains an option, but payment is not based on it. You are being paid to perform the pre-anesthesia assessment, monitor the patient intraoperatively, and provide indicated post-operative care. Here's how Novitas—the Medicare Part B administrative contractor for several states—describes the provider's role in its MAC policy:
During MAC, the patient's oxygenation, ventilation, circulation and temperature should be evaluated by whatever methods are deemed most suitable by the attending anesthetist. It is anticipated that newer methods of non-invasive monitoring such as pulse oximetry and capnography will be frequently relied upon. 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.
So, it's the monitoring (not the sedation) that's emphasized in anticipation of the need for anesthetic intervention, including general anesthesia, should that become necessary. Let's look now at the official position on MAC published by the American Society of Anesthesiologists (ASA):
Monitored anesthesia care includes all aspects of anesthesia care—a preprocedure assessment and optimization, intraprocedure care and postprocedure management that is inherently provided by a qualified anesthesia provider as part of the bundled specific service. During monitored anesthesia care, the anesthesiologist provides or medically directs a number of specific services, including but not limited to:
- Preprocedural assessment and management of patient comorbidity and periprocedural risk
- Diagnosis and treatment of clinical problems that occur during the procedure
- Support of vital functions inclusive of hemodynamic stability, airway management and appropriate management of the procedure induced pathologic changes as they affect the patient's coexisting morbidities
- Administration of sedatives, analgesics, hypnotics, anesthetic agents or other medications as necessary for patient safety
- Psychological support and physical comfort
- Provision of other medical services as needed to
complete the procedure safely
Monitored anesthesia care may include varying levels of sedation, awareness, analgesia and anxiolysis as necessary.
Notice again that the emphasis is on monitoring. When drugs are eventually addressed near the end of the excerpt, the policy does not require their usage but only that they be administered "as necessary," stating that they "may" be included in the service. In other words, the decision to use (or not use) an anesthetic agent in a MAC case is up to the clinical judgment of the provider.
Is It Really MAC?
All this raises a question. Don't most planned MAC cases today involve some type of sedation? Yes, that's our understanding from the many conversations we've had with our client groups over the years. Is that a problem? Well, let's talk about that. You may recall that the same ASA that put out the above description also defined the distinction between a general and a MAC service several years ago in its position statement on monitored anesthesia care. The 2018 edition of that publication states in pertinent part:
If the patient loses consciousness and the ability to respond purposefully, the anesthesia is a general anesthetic, irrespective of whether airway instrumentation is required.
Without belaboring the point, a MAC may be listed in your anesthesia plan. However, if you are routinely using propofol or a combination of drugs that cause the patient to lose consciousness, your MAC service is now considered a general—at least from the ASA's perspective—and you should document the anesthesia record accordingly.
Case Context
According to the health news website, Healthline, monitored anesthesia care is typically used for quick procedures and "is the first choice in 10 to 30 percent of all surgical procedures." However, MAC is more associated with a specified range of case types, such as endoscopy, dental procedures, bronchoscopy, eye surgery, otolaryngologic surgery and pain management injections. These are the types of procedures that payers are reluctant to reimburse from an anesthesia perspective, based on their assertion that such services are not typically necessary.
As an example of this reluctance, let's take a look at Anthem's 2021 GI MAC policy. It states:
Monitored anesthesia care is considered medically necessary during gastrointestinal endoscopic procedures when there is documentation by the operating physician or the anesthesiologist that demonstrates any of the following higher risk situations exist:
The policy then goes on to list nine conditions supporting medical necessity for MAC, such as issues dealing with age, pregnancy and agitation. The policy concludes by saying:
The routine assistance of an Anesthesiologist or Certified Registered Nurse Anesthetist (CRNA) for individuals not meeting the above criteria who are undergoing gastrointestinal endoscopic procedures is considered not medically necessary.
So, unless there are certain patient conditions present and documented, MAC or any other service provided by an anesthesia provider may be denied in GI cases, depending on the payer. Monitored anesthesia care for use in chronic pain cases can also be a bit dicey. The following excerpt is from a local coverage determination (LCD) found in the Medicare Coverage Database, effective April 2021:
General anesthesia is considered not reasonable and necessary for facet joint interventions. Neither conscious sedation nor monitored anesthesia care (MAC) is routinely necessary for intraarticular facet joint injections or medial branch blocks and are not routinely reimbursable. Individual consideration may be given on redetermination (appeal) for payment in rare, unique circumstances if the medical necessity of sedation is unequivocal and clearly documented in the medical record. Frequent reporting of these services together may trigger focused medical review.
What is interesting to note here is that, while a general anesthetic is automatically off the table for facet joint interventions (to include injections), the LCD holds out a sliver of hope when MAC is used. That is a bit of a turnaround from the days when certain payer policies would put significant conditions on paying a MAC case, but not so much if the provider marked "general."
The bottom line is that MAC is a bit tricky. Its nature and the conditions for getting it paid have evolved over the years; and some might make the argument that there are very few true MAC services being performed today, given the widespread use of propofol in these cases. Whenever you do have a true MAC on your hands, it becomes all the more important to list physical status and secondary patient conditions that may bolster your odds of getting paid.
If you have further questions about MAC, please contact your account executive or reach out to us at info@anesthesiallc.com.
With best wishes,
Tony Mira
President and CEO