Clinical UM Guideline

 

Subject: Anesthesia for Cataract Surgery
Guideline #: CG-MED-60 Publish Date:    12/27/2017
Status: New Last Review Date:    11/02/2017

Description

This document addresses the medical necessity of anesthesia services for cataract surgery. 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 strategies such as infiltration or topical applications.

This document does not address reimbursement for anesthesia services and is not intended to explain billing and reimbursement for anesthesia services. 

Note: Please see the following related documents for additional information:

Clinical Indications

Medically Necessary:

Administration of topical, regional, or local anesthesia for cataract surgery is considered medically necessary.

Administration of moderate sedation (“conscious sedation”), monitored anesthesia care (MAC), or general anesthesia for cataract surgery is considered medically necessary for any one of the following:

Not Medically Necessary:

Administration of moderate sedation (“conscious sedation”), monitored anesthesia care (MAC), or general anesthesia for cataract surgery is considered not medically necessary for all other indications and when criteria above is not met.

Coding

The following codes for treatments and procedures applicable to this guideline 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

 

00142

Anesthesia for procedures on eye; lens surgery [when specified as cataract surgery]

99151-99153

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; [includes codes 99151, 99152, 99153] [when specified as cataract surgery]

99155-99157

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; [includes codes 99155, 99156, 99157] [when specified as cataract surgery]

 

 

ICD-10 Diagnosis

 

E10.36

Type 1 diabetes mellitus with diabetic cataract

E11.36

Type 2 diabetes mellitus with diabetic cataract

H25.011-H25.9

Age-related cataract

H26.001-26.9

Other cataract

H28

Cataract in diseases classified elsewhere

Q12.0

Congenital cataract

Z98.41-Z98.49

Cataract extraction status

Discussion/General Information

 

Cataract is a clouding of the eye’s lens. According to the Centers for Disease Control and Prevention (CDC), cataracts are the leading cause of vision loss in the United States effecting an estimated 20.5 million Americans over the age of 40 (CDC, 2015). Treatment of cataracts can include eyeglasses and brighter lighting. Definitive therapy includes surgery which removes and replaces the cloudy lens with an artificial lens.

 

Anesthesia services are provided by or under the supervision of a physician. Services consist of the administration of an appropriate anesthetic agent and subsequent monitoring.

 

According to the American Academy of Ophthalmology (AAO) Preferred Practice Pattern® for Cataract in the Adult Eye (2016), a variety of anesthesia techniques can be used during cataract surgery including local or regional anesthesia, and general anesthesia. While the preferred method of anesthesia is local or regional anesthesia, general anesthesia may be necessary depending on an individual’s medical, psychosocial, or surgical condition.

 

Definitions

American Society of Anesthesiologists Definition of General Anesthesia and Levels of Sedation/Analgesia* (2014):

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

Moderate Sedation/Analgesia ("Conscious Sedation"): 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: 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: a drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation. The ability to independently maintain ventilatory function is often impaired. Patients often 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*** individuals 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 an individual 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.

Monitored Anesthesia Care (MAC)*: MAC was developed in response to more surgical and diagnostic services provided in an ambulatory, outpatient, or office setting where traditional general anesthetic would not be used. A combination of local, regional and certain conscious altering drugs, along with patient monitoring, is referred to as MAC if directly provided by anesthesia personnel. Based on the ASA's standards for monitoring, MAC should be provided by qualified anesthesia personnel (anesthesiologists or qualified anesthetists such as certified registered nurse anesthetist [CRNA]). These personnel must be continuously present to monitor the individual and provide anesthesia care.

References

Government Agency, Medical Society, and Other Authoritative Publications:

  1. American Academy of Ophthalmology. Preferred Practice Pattern®: Cataract in the adult eye. 2016. For additional information visit the AAO website: https://www.aao.org/preferred-practice-pattern/cataract-in-adult-eye-ppp-2016. Accessed on September 14, 2017.
  2. American Society of Anesthesiologists. Continuum of depth of sedation definition of general anesthesia and levels of sedation/analgesia. (Approved by ASA House of Delegates on October 13, 1999, and amended on October 15, 2014). For additional information visit the ASA website: http://www.asahq. Accessed on September 14, 2017.
  3. American Society of Anesthesiologists. ASA Physical Status Classification System. Approved by the ASA House of Delegates on October 15, 2014. For additional information visit the ASA website: http://www.asahq.org. Accessed on September 14, 2017.
  4. American Society of Anesthesiologists. ASA Position on Monitored Anesthesia Care. (Approved by the House of Delegates on October 21, 1986, and last updated on October 16, 2013). For additional information visit the ASA website: http://www.asahq.org. Accessed on September 14, 2017.
  5. American Society of Anesthesiologists. Statement on Practice Recommendations for Pediatric Anesthesia. (Approved by the ASA House of Delegates on October 19, 2011 and reaffirmed on October 26, 2016). For additional information visit the ASA website: http://www.asahq.org. Accessed on September 14, 2017.
  6. American Society of Anesthesiologists. Statement on regional anesthesia. (Approved by the ASA House of Delegates on October 12, 1983, and last amended on October 17, 2012). For additional information visit the ASA website: http://www.asahq.org. Accessed on September 14, 2017.
  7. National Eye Institute. Facts about Cataract. Last Reviewed September 2015. Available at: https://nei.nih.gov/health/cataract/cataract_facts. Accessed on September 14, 2017.
Websites for Additional Information
  1. Centers for Disease Control and Prevention. Common Eye Disorders. Last updated September 29, 2015. Available at: https://www.cdc.gov/visionhealth/basics/ced/index.html. Accessed on September 14, 2017
Index

Anesthesia
Cataract

History

Status

Date

Action

New

11/02/2017

Medical Policy & Technology Assessment Committee (MPTAC) review. Initial document development.