Clinical UM Guideline

 

Subject: Anesthesia Services and Moderate (“Conscious”) Sedation
Guideline #:  CG-MED-21 Publish Date:    10/17/2018
Status: Reviewed Last Review Date:    09/13/2018

Description

This document addresses the medical necessity of anesthesia services. Anesthesia services include all services associated with the administration and monitoring of analgesia or anesthesia in order to produce partial or complete loss of sensation. Examples of various methods of anesthesia include general anesthesia, regional anesthesia, monitored anesthesia care (MAC), moderate sedation (“conscious sedation”), and local infiltration or topical application.

Note: This document does not address anesthesia services performed during gastrointestinal endoscopic procedures. Also, please see the following documents for additional information:

This document does not address whether or not reimbursement is provided for the anesthesia service and is not intended to explain the billing and reimbursement of anesthesia.

Clinical Indications

Medically Necessary:

General Anesthesia or Regional Anesthesia

Administration of general or regional anesthesia is considered medically necessary when both of the following criteria are met:

  1. The services are provided by an individual other than the attending physician performing the procedure; and
  2. 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 of anesthesia service, a medical necessity review will be performed. This review will assess not only the procedure involved, but also other individual-specific issues, such as age, mental status, ability to cooperate, co-morbid conditions, and general medical status.

Monitored Anesthesia Care (MAC)

Monitored anesthesia care (MAC) is considered medically necessary when all of the following criteria are met:

  1. MAC is requested by the attending physician; and
  2. The services are provided by an individual other than the attending physician performing the procedure; and
  3. Qualified anesthesia personnel (anesthesiologists or qualified anesthetists such as certified registered nurse anesthetists) administering monitored anesthesia care are continuously present to monitor the individual and provide anesthesia care; and
  4. The individual's medical condition requires medical direction or supervision of the anesthetic to ensure control of the sedation, medication, and airway, and to prevent sudden changes in condition from disrupting the procedure and placing the individual at risk; and
  5. Constant monitoring of the individual’s vital signs is provided 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 procedure may become more extensive, or result in unforeseen complications, requires comprehensive monitoring or anesthetic intervention; and
  6. Appropriate documentation is available to reflect pre- and post-anesthetic evaluations and intraoperative monitoring.

Anesthesia Services including MAC for Surgical Procedures
For surgical procedures which do not usually require anesthesia services, anesthesia services including monitored anesthesia care (MAC) are considered medically necessary when the individual's condition requires the presence of qualified anesthesia personnel to perform monitored anesthesia in addition to the physician performing the procedure, and is so documented. The medical condition must be significant enough to impact the need to provide anesthesia services including MAC. Complex procedures and procedures in high-risk individuals may justify the use of an anesthesiologist or anesthetist to provide conscious sedation or deep sedation. See Appendix for physical status classifications. The presence of a stable, treated condition of itself is not necessarily sufficient.

Anesthesia Services including MAC for Interventional Pain Management Procedures
For interventional pain management procedures, including but not limited to nerve blocks, anesthesia services including monitored anesthesia care (MAC) are considered medically necessary when the following criteria have been met:

  1. There is documentation that the individual's condition requires the presence of qualified anesthesia personnel to perform monitored anesthesia in addition to the physician performing the procedure; and
  2. The medical condition or procedure must be significant enough to require the need for anesthesia services, including MAC. Such conditions or procedures may include, but are not limited to the following:
    1. Significant medical conditions (ASA physical status 3 or above) that increase risk for complications including cardiac disease, pulmonary disease, and morbid obesity (body mass index [BMI] greater than or equal to 40 kg/m2); or
    2. Sleep apnea; or
    3. History of complications during sedation; or
    4. Severe anxiety, psychiatric conditions, or cognitive impairments that decrease safety during the procedure; or
    5. Spasticity or neurological conditions that decrease safety during the procedure; or
    6. Procedures requiring individuals to remain motionless for a prolonged period of time; or
    7. Procedures requiring individuals to remain in a painful position; or
    8. Individuals under the age of 18.

Note: Complex procedures and procedures in high-risk individuals may justify the use of an anesthesiologist or anesthetist to provide conscious sedation or deep sedation. See Appendix for physical status classifications. The presence of a stable, treated condition of itself is not necessarily sufficient.

Moderate (“Conscious”) Sedation
Moderate sedation (“conscious sedation”) ordered by the attending physician and administered by the surgeon or physician performing the procedure or an independent trained practitioner is considered medically necessary when alternative types of anesthesia, sedation, or analgesia are not appropriate.

Local Anesthesia
The administration of local anesthesia is considered medically necessary when alternative types of anesthesia, sedation, or analgesia are not appropriate.

Standby Anesthesia Services
Standby anesthesia service is when the anesthesiologist would be immediately available if a clinical need should arise but the anesthesiologist may be elsewhere performing other duties. Stand-by anesthesia is considered medically necessary when a procedure, which does not normally require anesthesia services, has a significant potential for catastrophic complications or potential for the need of other intervention that would require immediate availability of general anesthesia.

Not Medically Necessary:

Anesthesia services are considered not medically necessary for all other indications.

Coding

The following codes for treatments and procedures applicable to this document are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

CPT

 

00100-00222

Anesthesia 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]

00300-00352

Anesthesia for procedures on the neck [includes codes 00300, 00320, 00322, 00326, 00350, 00352]

00400-00474

Anesthesia for procedures on the thorax [includes codes 00400, 00402, 00404, 00406, 00410, 00450, 00454, 00470, 00472, 00474]

00500-00580

Anesthesia 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]

00600-00670

Anesthesia for procedures on spine and spinal cord [includes codes 00600, 00604, 00620, 00625, 00626, 00630, 00632, 00635, 00640, 00670]

00700-00797

Anesthesia for procedures on upper abdomen [includes codes 00700, 00702, 00730, 00750, 00752, 00754, 00756, 00770, 00790, 00792, 00794, 00796, 00797]

00800-00882

Anesthesia 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]

00902-00952

Anesthesia 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]

01112-01190

Anesthesia for procedures on pelvis [includes codes 01112, 01120, 01130, 01140, 01150, 01160, 01170, 01173, 01180, 01190]

01200-01274

Anesthesia for procedures on upper leg [includes codes 01200, 01202, 01210, 01212, 01214, 01215, 01220, 01230, 01232, 01234, 01250, 01260, 01270, 01272, 01274]

01320-01444

Anesthesia 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]

01462-01522

Anesthesia for procedures on lower leg [includes codes 01462, 01464, 01470, 01472, 01474, 01480, 01482, 01484, 01486, 01490, 01500, 01502, 01520, 01522]

01610-01682

Anesthesia for procedures on shoulder and axilla [includes codes 01610, 01620, 01622, 01630, 01634, 01636, 01638, 01650, 01652, 01654, 01656, 01670, 01680, 01682]

01710-01782

Anesthesia 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]

01810-01860

Anesthesia for procedures on forearm, wrist, and hand [includes codes 01810, 01820, 01829, 01830, 01832, 01840, 01842, 01844, 01850, 01852, 01860]

01905-01953

Anesthesia for radiological procedures, burn excisions or debridement [includes codes 01916, 01920, 01922, 01924, 01925, 01926, 01930, 01931, 01932, 01933, 01935, 01936, 01951, 01952, 01953]

01958-01969

Anesthesia for obstetric procedures [includes codes 01958, 01960, 01961, 01962, 01963, 01965, 01966, 01967, 01968, 01969]

01990-01999

Other anesthesia procedures [includes codes 01990, 01991, 01992, 01996, 01999]

99100

Anesthesia for patient of extreme age, younger than 1 year and older than 70

99116

Anesthesia complicated by utilization of total body hypothermia

99135

Anesthesia complicated by utilization of controlled hypotension

99140

Anesthesia complicated by emergency conditions (specify)

99151

Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient younger than 5 years of age

99152

Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 5 years or older

99153

Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; each additional 15 minutes of intraservice time

99155

Moderate sedation services provided by a physician or other qualified health care professional other than the physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports; initial 15 minutes of intraservice time, patient younger than 5 years of age

99156

Moderate sedation services provided by a physician or other qualified health care professional other than the physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports; initial 15 minutes of intraservice time, patient age 5 years or older

99157

Moderate sedation services provided by a physician or other qualified health care professional other than the physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports; each additional 15 minutes of intraservice time

 

 

 

CPT Physical Status Modifiers

P1

A normal healthy patient (Class I)

P2

A patient with mild systemic disease (Class II)

P3

A patient with severe systemic disease (Class III)

P4

A patient with severe systemic disease that is a constant threat to life (Class IV)

P5

A moribund patient who is not expected to survive without the operation (Class V)

 

 

HCPCS

 

G0500

Moderate sedation services provided by the same physician or other qualified health care professional performing a gastrointestinal endoscopic service that sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intra-service time; patient age 5 years or older

 

 

 

HCPCS Anesthesia Modifiers

AA

Anesthesia services performed personally by anesthesiologist

AD

Medical supervision by a physician: more than four concurrent anesthesia procedures

G8

Monitored anesthesia care (MAC) for deep complex, complicated, or markedly invasive surgical procedure

G9

Monitored anesthesia care for patient who has history of severe cardio-pulmonary condition

QK

Medical direction of two, three, or four concurrent anesthesia procedures involving qualified individuals

QS

Monitored anesthesia care service

QX

CRNA service: with medical direction by a physician

QY

Medical direction of one certified registered nurse anesthetist (CRNA) by an anesthesiologist

QZ

CRNA service: without medical direction by a physician

 

 

ICD-10 Diagnosis

 

 

All diagnoses

Discussion/General Information

Anesthesia services are provided by or under the supervision of a physician. Services consist of the administration of an anesthetic agent in various types of anesthesia.

Types of Anesthesia and Anesthesia Services

Anesthesia Service by the Surgeon: Anesthesia services personally furnished by the physician performing the surgical, therapeutic or diagnostic procedure are considered an integral component of the primary procedure. This may include local injections, regional blocks, and intravenous medication. General anesthesia administered and monitored by the surgeon is not considered medically appropriate.

Balanced Anesthesia: Anesthesia that uses a combination of drugs, each in an amount sufficient to produce its major or desired effect to the optimum degree and keep its undesirable or unnecessary effects to a minimum.

Bier Block/Intravenous Regional Anesthesia (IVRA): Regional anesthesia produced by intravenous injection, used for surgical procedures on the arm below the elbow or the leg below the knee; performed in a bloodless field maintained by a pneumatic tourniquet that also prevents the anesthetic from entering the systemic circulation.

Brachial Plexus Block/Brachial Plexus Anesthesia: Regional anesthesia of the shoulder, arm, and hand by injection of a local anesthetic into the brachial plexus.

Caudal Block/Caudal Anesthesia: Regional anesthesia produced by injection of a local anesthetic into the caudal or sacral canal.

Epidural Block/Epidural Anesthesia: Regional anesthesia produced by injection of the anesthetic agent between the vertebral spines and beneath the ligamentum flavum into the epidural space.

General Anesthesia: A reversible state of unconsciousness and the inability to perceive pain, produced by anesthetic agents, with absence of pain sensation over the entire body and a greater or lesser degree of muscular relaxation; the drugs producing this state can be administered by inhalation, intravenously, intramuscularly, rectally, or via the gastrointestinal tract.

Inhalation Anesthesia: Anesthesia produced by the inhalation of vapors of a volatile liquid or gaseous anesthetic agent.

Intercostal Block/Intercostal Anesthesia: Anesthesia produced by blocking intercostal nerves with a local anesthetic.

Intranasal Anesthesia: Local anesthesia produced by insertion into the nasal fossae of pledgets soaked in a solution of an anesthetic agent which is effective after topical application, or by insufflation of a mixture of anesthetic gases or vapors through a tube introduced into the nose.

Intraoral Anesthesia: Anesthesia produced within the oral cavity by injection, spray, pressure, etc.

Intrathecal Anesthesia: Anesthesia produced by injection of an anesthetic solution into the subarachnoid space.

Intravenous Anesthesia/Intravenous Sedation (IV Sedation): Anesthesia produced by introduction of an anesthetic agent into a vein.

Local Anesthesia: Anesthesia confined to one area of the body.

Moderate (“Conscious”) Sedation: Involves the administration of medication with or without analgesia to achieve a state of depressed consciousness while maintaining the individual's ability to respond to stimulation. Moderate (“conscious”) sedation is administered by the surgeon or physician performing the procedure or an independent trained practitioner for the purpose of assisting the physician in monitoring the individual's level of consciousness and physiological status. It includes pre- and post-sedation evaluations, administration of the sedation and monitoring of the cardiorespiratory function. Cardiorespiratory functions monitored include heart rate, blood pressure and oxygen level.

Monitored Anesthesia Care (MAC): MAC was developed in response to the shift to providing more surgical and diagnostic services in an ambulatory, outpatient or office setting without the use of the traditional general anesthetic. Accompanying this, there has been a change in the provision of anesthesia services from the traditional general anesthetic to a combination of local, regional and certain consciousness altering drugs. This type of anesthesia is referred to as MAC if directly provided by anesthesia personnel. Based on the American Society of Anesthesiologists' (ASA) standards for monitoring, MAC should be provided by qualified anesthesia personnel (anesthesiologists or qualified anesthetists such as certified registered nurse anesthetists). These individuals must be continuously present to monitor and provide anesthesia care.

As described by the ASA’s Position on Monitored Anesthesia Care (2013):

Monitored anesthesia care is a specific anesthesia service for a diagnostic or therapeutic procedure. Indications for monitored anesthesia care include the nature of the procedure, the patient’s clinical condition or the potential need to convert to a general or regional anesthetic.

Monitored anesthesia care includes all aspects of anesthesia care – a preprocedure visit, intraprocedure care and postprocedure anesthesia management. During monitored anesthesia care, the anesthesiologist provides or medically directs a number of specific services, including but not limited to:

Monitored anesthesia care may include varying levels of sedation, analgesia, and anxiolysis as necessary. The provider of monitored anesthesia care must be prepared and qualified to convert to general anesthesia when necessary. If the patient loses consciousness and the ability to respond purposefully, the anesthesia care is a general anesthetic, irrespective of whether airway instrumentation is required.

As described by the ASA’s Statement on Anesthetic Care During Interventional Pain Procedures for Adults (2016):

The use of moderate (conscious) sedation and/or anesthesia during the performance of pain procedures must be balanced with the potential risk of harm from doing pain procedures in sedated patients…Many patients can undergo interventional pain procedures without the need for supplemental sedation in addition to local anesthesia. For most patients who require supplemental sedation, the physician performing the interventional pain procedure(s) can provide moderate (conscious) sedation as part of the procedure. For a limited number of patients a second provider may be required to manage moderate or deep sedation or, in selected cases other anesthesia services. Examples of procedures that typically do not require sedation include but are not limited to epidural steroid injections, epidural blood patch, trigger point injections, injections into the shoulder, hip, knee, facet, and sacroiliac joints, and occipital nerve blocks.

Significant anxiety may be an indication for moderate (conscious) sedation or anesthesia services. In addition, procedures that require the patient to remain motionless for a prolonged period of time and/or remain in a painful position may require sedation or anesthesia services. Examples of such procedures include but are not limited to sympathetic blocks (celiac plexus, paravertebral and hypogastric), chemical or radiofrequency ablation, percutaneous discectomy, trial spinal cord stimulator lead placement, permanent spinal cord stimulator generator and lead implantation, and intrathecal pump implantation. Major nerve/plexus blocks are performed less often in the chronic pain clinic, but the Committee believes that these blocks may more commonly require moderate (conscious) sedation or anesthesia services (e.g., brachial plexus block, sciatic nerve block, and continuous catheter techniques). The Committee recognizes that pediatric patients may require sedation or anesthesia services for pain procedures because of age-related differences in the approach to this patient population.

Regional Anesthesia: Anesthesia that involves the use of local anesthetic solutions(s) to produce circumscribed areas of loss of sensation. This includes spinal, epidural, nerve, field and extremity blocks. Spinal and epidural anesthesia is produced by injection of local anesthetic solution near the spinal canal, which interrupts sensation from the legs or abdomen.

Sacral Block/Sacral Anesthesia: Anesthesia produced by injection of a local anesthetic into the extradural space of the sacral canal.

Saddle Block Anesthesia: A type of sacral anesthesia produced in a region corresponding roughly with the area of the buttocks, perineum, and inner aspects of the thighs, by introducing the anesthetic agent low in the dural sac.

Spinal Anesthesia: Regional anesthesia produced by injection of a local anesthetic into the subarachnoid space around the spinal cord.

Standby Anesthesia: Anesthesia standby occurs when the anesthesiologist, or the CRNA, is available in the facility in the event he or she is needed for a procedure that requires anesthesia (e.g., available in the facility in case of obstetric complications - breech presentation, twins, and trial of instrumental delivery), but is not physically present or providing services. Standby anesthesia is not direct care (for instance, it is a standby service without direct hands-on contact).

Topical Anesthesia: Anesthesia produced by application of a local anesthetic directly to the area involved.

American Society of Anesthesiologists Levels of Sedation/Analgesia (ASA, 2014)

Minimal Sedation (Anxiolysis) is a drug-induced state during which patients respond normally to verbal commands. Although cognitive function and coordination may be impaired, ventilatory and cardiovascular functions are unaffected.

Moderate Sedation/Analgesia (“Conscious Sedation”) is a drug-induced depression of consciousness during which patients respond purposefully** to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained.

Deep Sedation/Analgesia is a drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully** following repeated or painful stimulation. The ability to independently maintain ventilatory function may be impaired. Patients may require assistance in maintaining a patent airway, and spontaneous ventilation may be inadequate. Cardiovascular function is usually maintained.

General Anesthesia is a drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation. The ability to independently maintain ventilatory function may be impaired. Patients may require assistance in maintaining a patent airway, and positive pressure ventilation may be required because of depressed spontaneous ventilation or drug-induced depression of neuromuscular function. Cardiovascular function may be impaired.

Because sedation is a continuum, it is not always possible to predict how an individual patient will respond. Hence, practitioners intending to produce a given level of sedation should be able to rescue*** patients whose level of sedation becomes deeper than initially intended. Individuals administering Moderate Sedation/Analgesia (“Conscious Sedation”) should be able to rescue*** patients who enter a state of Deep Sedation/Analgesia, while those administering Deep Sedation/Analgesia should be able to rescue*** patients who enter a state of General Anesthesia.

*Monitored Anesthesia Care does not describe the continuum of depth of sedation, rather it describes “a specific anesthesia service in which an anesthesiologist has been requested to participate in the care of a patient undergoing a diagnostic or therapeutic procedure.”

**Reflex withdrawal from a painful stimulus is NOT considered a purposeful response.

***Rescue of a patient from a deeper level of sedation than intended is an intervention by a practitioner proficient in airway management and advanced life support. The qualified practitioner corrects adverse physiologic consequences of the deeper-than-intended level of sedation (such as hypoventilation, hypoxia and hypotension) and returns the patient to the originally intended level of sedation. It is not appropriate to continue the procedure at an unintended level of sedation.

References

Government Agency, Medical Society, and Other Authoritative Publications:

  1. American Society of Anesthesiologists. Position on monitored anesthesia care. Approved by the House of Delegates on October 25, 2005, and last updated on October 16, 2013. For additional information visit the ASA website: http://www.asahq.org. Accessed on August 10, 2018.
  2. American Society of Anesthesiologists. ASA physical status classification system. Last approved by the ASA House of Delegates on October 15, 2014. For additional information visit the ASA website: http://www.asahq.org. Accessed on August 10, 2018.
  3. American Society of Anesthesiologists. Continuum of depth of sedation: definition of general anesthesia and levels of sedation/analgesia. Committee of origin: Quality Management and Departmental Administration. Approved by the ASA House of Delegates on October 13, 1999, and last amended on October 15, 2014. For additional information visit the ASA website: http://www.asahq.org. Accessed on August 10, 2018.
  4. American Society of Anesthesiologists. Statement on anesthetic care during interventional pain procedures for adults. Committee of origin: Pain Medicine. Approved by the ASA House of Delegates on October 22, 2005 and last amended on October 26, 2016. For additional information visit the ASA website: http://www.asahq.org. Accessed on August 10, 2018.
  5. American Society of Anesthesiologists. Statement on granting privileges for administration of moderate sedation to practitioners who are not anesthesia professionals. Committee of origin: Ad Hoc Committee on Credentialing. Committee of review: Ambulatory Surgical Care. Approved by the ASA House of Delegates on October 25, 2005, and reaffirmed on October 26, 2016. For additional information visit the ASA website: http://www.asahq.org. Accessed on August 10, 2018.
  6. American Society of Anesthesiologists. Statement on regional anesthesia. Committee of origin: Regional Anesthesia. Approved by the ASA House of Delegates on October 12, 1983 and last amended on October 25, 2017. For additional information visit the ASA website: http://www.asahq.org. Accessed on August 10, 2018.
  7. American Society of Anesthesiologists. Committee of origin: Quality Management and Departmental Administration. Approved by the ASA House of Delegates on October 20, 2010 and last amended on October 25, 2017. For additional information visit the ASA website: http://www.asahq.org. Accessed on August 10, 2018.
  8. American Society of Anesthesiologists. Statement on granting privileges to non-anesthesiologist physicians for personally administering or supervising deep sedation. Committee of origin: Quality Management and Departmental Administration. Approved by the ASA House of Delegates on October 18, 2006 and last amended on October 25, 2017. For additional information visit the ASA website: http://www.asahq.org. Accessed on August 10, 2018.
  9. American Society of Anesthesiologists. Practice guidelines for moderate procedural sedation and analgesia 2018: a report by the American Society of Anesthesiologists Task Force on Moderate Procedural Sedation and Analgesia, the American Association of Oral and Maxillofacial Surgeons, American College of Radiology, American Dental Association, American Society of Dentist Anesthesiologists, and Society of Interventional Radiology. March 2018. For additional information visit the ASA website: http://www.asahq.org. Accessed on August 10, 2018.
Index

 

Anesthesia Services

Conscious Sedation

General Anesthesia

Moderate Sedation

Monitored Anesthesia Care (MAC)

Regional Anesthesia

 

History

Status

Date

Action

Reviewed

09/13/2018

Medical Policy & Technology Assessment Committee (MPTAC) review. Discussion/General Information and References sections updated.

Revised

11/02/2017

MPTAC review. Added a statement for when interventional pain management procedures are medically necessary. Updated Discussion and References sections. The document header wording updated from “Current Effective Date” to “Publish Date.” Updated Coding section with 01/01/2017 CPT changes; 01180, 01190, 01682 deleted 12/31/2017.

Reviewed

05/04/2017

MPTAC review. Formatting updated in Clinical Indications section. Description and References sections updated.

 

01/01/2017

Updated Coding section with 01/01/2017 CPT and HCPCS changes; removed codes 99143, 99144, 99145, 99148, 99149, 99150 deleted 12/31/2016 and codes for nerve blocks which are not used for anesthesia during procedures.

Reviewed

05/05/2016

MPTAC review. References section updated.

 

01/01/2016

Updated Coding section with 01/01/2016 CPT changes, removed 64412 deleted 12/31/2015; also removed ICD-9 codes.

Reviewed

05/07/2015

MPTAC review. Description, Discussion and References sections updated.

 

01/01/2015

Updated Coding section with 01/01/2015 CPT changes; removed 00452, 00622, 00634 deleted 12/31/2014.

Reviewed

05/15/2014

MPTAC review. References section updated.

Reviewed

05/09/2013

MPTAC review. References updated.

Reviewed

05/10/2012

MPTAC review. References updated.

Reviewed

05/19/2011

MPTAC review. References updated.

Reviewed

05/13/2010

MPTAC review. Discussion and References updated.

 

01/01/2010

Updated Coding section with 01/01/2010 CPT changes; removed CPT 01632 deleted 12/31/2009.

Reviewed

05/21/2009

MPTAC review. Discussion, Coding and References updated. Place of service section removed.

Revised

05/15/2008

MPTAC review. Added a statement for when anesthesia services are not medically necessary. References and Appendix updated. Coding updated with 01/01/2008 CPT updates; removed CPT 01905 deleted 12/31/2007.

Reviewed

05/17/2007

MPTAC review. References updated.

Revised

06/08/2006

MPTAC review. Document title revised. Term conscious sedation updated to moderate sedation per ASA guidelines. Updated definition of MAC per ASA guidelines. Indications for anesthesia services during gastrointestinal endoscopic procedures removed. References updated. 

Revised

03/23/2006

MPTAC review. Updated language for regional anesthesia. Revision per recommendation from American Society of Anesthesiologists.

 

01/01/2006

Updated coding section with 01/01/2006 CPT/HCPCS changes.

Revised

09/22/2005

MPTAC review. Revision based Pre-merger Anthem and Pre-merger WellPoint Harmonization.

Pre-Merger Organizations

Last Review Date

Document Number

Title

 

Anthem, Inc.

 

 

No document

WellPoint Health Networks, Inc.

04/28/2005

Definition vii

Anesthesia Services

Appendix

American Society of Anesthesiology Physical Status Classifications:

ASA I    A normal healthy patient

ASA II   A patient with mild systemic disease

ASA III  A patient with severe systemic disease

ASA IV  A patient with severe systemic disease that is a constant threat to life

ASA V   A moribund patient who is not expected to survive without the operation

ASA VI  A declared brain-dead patient whose organs are being removed for donor purposes