Local Coverage Determination (LCD):
Monitored Anesthesia Care (MAC) (L27489)
Contractor Information
Contractor Name
Novitas Solutions, Inc.
LCD Information
Document Information
LCD ID
L27489
LCD Title
Monitored Anesthesia Care (MAC)
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Medical Association. Applicable
FARS/DFARS Apply to Government Use. Fee
schedules, relative value units, conversion
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assigned by the AMA, are not part of CPT, and
the AMA is not recommending their use. The
AMA does not directly or indirectly practice
medicine or dispense medical services. The
AMA assumes no liability for data contained or
not contained herein. The Code on Dental
Procedures and Nomenclature (Code) is
published in Current Dental Terminology
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CMS National Coverage Policy
Original Effective Date
For services performed on or after 07/11/2008
Revision Effective Date
For services performed on or after 08/21/2014
Revision Ending Date
N/A
Retirement Date
N/A
Notice Period Start Date
05/15/2012
Notice Period End Date
07/05/2012
Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no Medicare payment
shall be made for items or services which are not reasonable and necessary for the diagnosis or
treatment of illness or injury.
Title XVIII of the Social Security Act, Section 1862(a)(7). This section excludes routine physical
examinations.
Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to
any provider for any claim that lacks the necessary information to process the claim.
Coverage Guidance
Coverage Indications, Limitations, and/or Medical Necessity
Compliance with the provisions in this policy may be monitored and addressed through post
payment data analysis and subsequent medical review audits.
The following Indications and Limitations are pertinent to any and all Monitored Anesthesia
Care (MAC) services in general, regardless of the procedure performed or the anesthesia drug(s)
administered.
With advances in modern medical technology, there has been a shift in supplying some surgical
and diagnostic services to an ambulatory, outpatient or office setting. 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 mind-altering drugs. Monitored Anesthesia Care
(MAC) requires careful and continuous evaluation of various vital physiological functions and
the diagnosis and treatment of any clinical observations or deviations. MAC can be provided by
a variety of qualified anesthesia personnel. However, such personnel must have training and
experience involving:
•
•
patient assessment
continuous evaluation and monitoring of patient physiological functions
•
diagnosis and treatment (both pharmacological and non-pharmacological) of any and all
deviations in physiological functions.
Also, adequate medical and pharmacological equipment must be readily available at all times
during MAC.
Coverage for MAC is allowed only when all of the following are satisfied:
•
•
•
•
the service is properly coded
documentation is clear and all documentation requirements are met
the service is reasonable and necessary
the facility requirements are met
MAC must be provided by qualified anesthesia personnel. These individuals must be
continuously present to monitor the patient and provide anesthesia care.
During MAC, the patient's oxygenation, ventilation, circulation and temperature (for those
patients at risk for hypothermia or malignant hyperthermia) should be evaluated by whatever
method is deemed most suitable by the attending anesthetist. 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.
During monitored anesthesia care, the attending anesthetist must provide a number of specific
services, including but not limited to all of the following:
•
•
•
•
•
•
Pre-procedure visit and evaluation
Intraprocedure monitoring of patient's vital signs, maintenance of the patient's airway and
continual evaluation of vital functions
Diagnosis and treatment of any clinical problems which occur during the procedure
Administration of sedatives, analgesics, hypnotics, anesthetic agents or other medications
as necessary to ensure patient safety and comfort
Provision of medical services as needed to accomplish the safe completion of the
procedure
Post-procedure anesthesia management
Facility-Equipment Requirements
The following facility and equipment requirements encourage quality patient care, but observing
them cannot guarantee any specific patient outcome. These requirements pertain to any and all
MAC services performed.
•
•
•
•
MAC location must have a reliable source of oxygen adequate for the length of the
procedure. There must also be a backup supply.
MAC location must have an adequate and reliable source of suction. Suction apparatus
that meets operating room standards is encouraged.
MAC locations in which inhalation anesthetics are administered must have an adequate
and reliable system for scavenging waste anesthetic gases.
Each MAC location must include:
a. a self-inflating hand resuscitator bag capable of administering at least 90 percent
oxygen as a means to deliver positive pressure ventilation
b. adequate anesthesia drugs, supplies and equipment for the intended anesthesia
care, and
c. adequate monitoring equipment to allow for all patients monitoring noted in
documentation requirements
d. each MAC location shall have immediately available an emergency cart with
defibrillator, emergency drugs and other equipment adequate to provide
cardiopulmonary resuscitation
The Centers for Medicare and Medicaid Services (CMS) requirements for this type of anesthesia
are the same as for general anesthesia. Specifically, the requirement includes the performance of
pre-anesthetic examination and evaluation, prescription of the anesthesia care required, the
completion of the anesthesia record, the administration of necessary oral or parenteral
medications and the provision of indicated post-operative anesthesia care. Appropriate
documentation must be available to reflect the pre and post-anesthetic evaluations and
intraoperative monitoring.
Reimbursement for MAC will be the same amount allowed for full general anesthesia services if
all the requirements listed under these indications are met. The provision of quality MAC is
mandatory and requires the same expertise and the same effort (work) as required in the delivery
of a general anesthetic. If the requirements are not fulfilled or the procedures are unnecessary,
payment will be denied in full.
The MAC service rendered must be reasonable, appropriate and medically necessary. The
presence of an underlying condition alone, as reported by an ICD-9 code, may not be sufficient
evidence that MAC is necessary. The medical condition must be significant enough to impact on
the need to provide MAC such as the patient being on medication or being symptomatic, etc. The
presence of a stable, treated condition in and of itself is not necessarily sufficient.
The codes listed in the "CPT/HCPCS Codes" section of this policy illustrate procedures that do
not usually require anesthesia services. However, MAC may be covered when the patient's
condition requires the presence of qualified anesthesia personnel to perform monitored
anesthesia in addition to the physician performing the procedure. The necessity for the MAC
service must be clearly reflected in the medical record.
Moderate anesthesia ( 99143, 99144, 99145, 99148, 99149, and 99150) is inherent in the
procedures listed in "Appendix G of CPT. It is usually provided by the attending surgeon, is
included in the global fee, and is not usually separately reimbursable. Moderate (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. Moderate sedation does not include minimal
sedation, deep sedation or monitored anesthesia care ( 00100-01999). However, in certain
instances, monitored anesthesia care (MAC), provided by anesthesia personnel may be necessary
for these procedures or other surgical procedures, if the patient’s diagnosis or pertinent medical
history is reflective of one or more of the conditions found in the "ICD-9 Codes That Support
Medical Necessity" section of this policy. Of the code range used to identify monitored
anesthesia care ( 00100-01999) the anesthesia procedures listed in the CPT/HCPCS Codes
section of this policy are the more likely anesthesia procedures to be billed separately from the
CPT codes in Appendix G of CPT. This policy defines the circumstances in which these
additional anesthesia services may be considered reasonable and necessary for those procedures,
as well as any circumstances for which MAC may be billed, provided all the other conditions of
monitored anesthesia care are met.
Also, the following indications/conditions will be considered on an individual basis when
reported for one of the services listed in the "CPT/HCPCS Codes" section of this policy.
Documentation to support the medical necessity of the service must be maintained in the
patient's clinical record. For coding guidelines specific to the indications/conditions listed below,
refer to the corresponding article for Monitored Anesthesia Care (MAC) (to follow).
•
•
•
•
•
•
•
Combative patients
Patients with low pain thresholds, who suffer severe pain or who are unable to tolerate
the planned procedure without MAC by documented history or as the procedure gets
underway)
Intraoperative expansion of procedure or strong possibility of expansion of a procedure
Any condition in a pediatric patient, Medicare eligible
Mental retardation (e.g., patients who are uncooperative due to a lack of understanding
caused by their mental disability)
The medically necessary administration of the anesthetic drug, propofol, which requires
the expertise of an M.D., D.O. (not directly performing the surgical/diagnostic procedure)
or a CRNA trained in its use.
The mere use of fentanyl, versed, or stadol, does not, justify the medical necessity of
monitored anesthesia care, since use of these is inherent in the surgical procedure itself.
Medical Necessity for Monitored Anesthesia Care requires that the patient meet one of
the conditions listed below from the Diagnoses that Support Medical Necessity
In summary, MAC may be necessary and justified when one of the CPT codes listed in the
"CPT/HCPCS Codes" section of this policy or propofol is coupled with one of the codes listed in
Appendix G of CPT or other minor procedures not usually requiring anesthesia to insure safety
by the prevention of adverse physiologic complications, in patients with one of the qualifying
ICD-9-CM codes. When reporting services that do not usually require MAC, append the
appropriate anesthesia modifier and the QS modifier (when a co-existing condition the "ICD-9
Codes That Support Medical Necessity" exists).
Limitation
Any MAC service reported not meeting the guidelines outlined in the "Indications and
Limitations of Coverage and/or Medical Necessity" section of this LCD is considered not
reasonable and necessary.
Coding Information
Bill Type Codes:
Contractors may specify Bill Types to help providers identify those Bill Types typically used to
report this service. Absence of a Bill Type does not guarantee that the policy does not apply to
that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by
Bill Type and the policy should be assumed to apply equally to all claims.
999x Not Applicable
Revenue Codes:
Contractors may specify Revenue Codes to help providers identify those Revenue Codes
typically used to report this service. In most instances Revenue Codes are purely advisory; unless
specified in the policy services reported under other Revenue Codes are equally subject to this
coverage determination. Complete absence of all Revenue Codes indicates that coverage is not
influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue
Codes.
99999 Not Applicable
CPT/HCPCS Codes
Group 1 Paragraph: Italicized and/or quoted material is excerpted from the American Medical
Association, Current Procedural Terminology (CPT) codes.
Below are anesthesia procedures for which anesthesia personnel provided services (MAC) are
usually not needed but may be medically necessary in certain limited situations (see "Indications
and Limitations of Coverage and/or Medical Necessity").
Group 1 Codes:
ANESTHESIA FOR PROCEDURES ON SALIVARY GLANDS, INCLUDING
BIOPSY
ANESTHESIA FOR PROCEDURES ON EXTERNAL, MIDDLE, AND INNER EAR
00124
INCLUDING BIOPSY; OTOSCOPY
00148 ANESTHESIA FOR PROCEDURES ON EYE; OPHTHALMOSCOPY
ANESTHESIA FOR PROCEDURES ON NOSE AND ACCESSORY SINUSES; NOT
00160
OTHERWISE SPECIFIED
ANESTHESIA FOR PROCEDURES ON NOSE AND ACCESSORY SINUSES;
00164
BIOPSY, SOFT TISSUE
ANESTHESIA FOR ALL PROCEDURES ON THE INTEGUMENTARY SYSTEM,
00300 MUSCLES AND NERVES OF HEAD, NECK, AND POSTERIOR TRUNK, NOT
OTHERWISE SPECIFIED
00100
ANESTHESIA FOR PROCEDURES ON THE INTEGUMENTARY SYSTEM ON THE
00400 EXTREMITIES, ANTERIOR TRUNK AND PERINEUM; NOT OTHERWISE
SPECIFIED
ANESTHESIA FOR PROCEDURES ON CLAVICLE AND SCAPULA; BIOPSY OF
00454
CLAVICLE
00524 ANESTHESIA FOR CLOSED CHEST PROCEDURES; PNEUMOCENTESIS
00532 ANESTHESIA FOR ACCESS TO CENTRAL VENOUS CIRCULATION
ANESTHESIA FOR PROCEDURES ON UPPER ANTERIOR ABDOMINAL WALL;
00702
PERCUTANEOUS LIVER BIOPSY
ANESTHESIA FOR UPPER GASTROINTESTINAL ENDOSCOPIC PROCEDURES,
00740
ENDOSCOPE INTRODUCED PROXIMAL TO DUODENUM
ANESTHESIA FOR LOWER INTESTINAL ENDOSCOPIC PROCEDURES,
00810
ENDOSCOPE INTRODUCED DISTAL TO DUODENUM
ANESTHESIA FOR INTRAPERITONEAL PROCEDURES IN LOWER ABDOMEN
00842
INCLUDING LAPAROSCOPY; AMNIOCENTESIS
ANESTHESIA FOR PROCEDURES ON MALE GENITALIA (INCLUDING OPEN
00920
URETHRAL PROCEDURES); NOT OTHERWISE SPECIFIED
ANESTHESIA FOR PROCEDURES ON MALE GENITALIA (INCLUDING OPEN
00921
URETHRAL PROCEDURES); VASECTOMY, UNILATERAL OR BILATERAL
01130 ANESTHESIA FOR BODY CAST APPLICATION OR REVISION
ANESTHESIA FOR ALL CAST APPLICATIONS, REMOVAL, OR REPAIR
01420
INVOLVING KNEE JOINT
01490 ANESTHESIA FOR LOWER LEG CAST APPLICATION, REMOVAL, OR REPAIR
ANESTHESIA FOR SHOULDER CAST APPLICATION, REMOVAL OR REPAIR;
01680
NOT OTHERWISE SPECIFIED
ANESTHESIA FOR SHOULDER CAST APPLICATION, REMOVAL OR REPAIR;
01682
SHOULDER SPICA
ANESTHESIA FOR PROCEDURES ON VEINS OF UPPER ARM AND ELBOW; NOT
01780
OTHERWISE SPECIFIED
ANESTHESIA FOR PROCEDURES ON VEINS OF UPPER ARM AND ELBOW;
01782
PHLEBORRHAPHY
ANESTHESIA FOR FOREARM, WRIST, OR HAND CAST APPLICATION,
01860
REMOVAL, OR REPAIR
01916 ANESTHESIA FOR DIAGNOSTIC ARTERIOGRAPHY/VENOGRAPHY
01922 ANESTHESIA FOR NON-INVASIVE IMAGING OR RADIATION THERAPY
01999 UNLISTED ANESTHESIA PROCEDURE(S)
ICD-9 Codes that Support Medical Necessity
Group 1 Paragraph: It is the provider’s responsibility to select codes carried out to the highest
level of specificity and selected from the ICD-9-CM code book appropriate to the year in which
the service is rendered for the claim(s) submitted.
Group 1 Codes:
038.0
STREPTOCOCCAL SEPTICEMIA
038.10 - STAPHYLOCOCCAL SEPTICEMIA UNSPECIFIED - METHICILLIN
038.12 RESISTANT STAPHYLOCOCCUS AUREUS SEPTICEMIA
038.19 OTHER STAPHYLOCOCCAL SEPTICEMIA
038.2
PNEUMOCOCCAL SEPTICEMIA
038.3
SEPTICEMIA DUE TO ANAEROBES
038.40 - SEPTICEMIA DUE TO GRAM-NEGATIVE ORGANISM UNSPECIFIED 038.44 SEPTICEMIA DUE TO SERRATIA
038.49 OTHER SEPTICEMIA DUE TO GRAM-NEGATIVE ORGANISMS
038.8 OTHER SPECIFIED SEPTICEMIAS - UNSPECIFIED SEPTICEMIA
038.9
242.00 - TOXIC DIFFUSE GOITER WITHOUT THYROTOXIC CRISIS OR STORM UNSPECIFIED ACQUIRED HYPOTHYROIDISM
244.9
SECONDARY DIABETES MELLITUS WITHOUT MENTION OF
249.00 - COMPLICATION, NOT STATED AS UNCONTROLLED, OR UNSPECIFIED 249.91 SECONDARY DIABETES MELLITUS WITH UNSPECIFIED COMPLICATION,
UNCONTROLLED
DIABETES MELLITUS WITHOUT MENTION OF COMPLICATION, TYPE II OR
250.00 - UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED - UNSPECIFIED
253.9
DISORDER OF THE PITUITARY GLAND AND ITS HYPOTHALAMIC
CONTROL
254.0 - PERSISTENT HYPERPLASIA OF THYMUS - UNSPECIFIED DISORDER OF
255.9
ADRENAL GLANDS
276.0 - HYPEROSMOLALITY AND/OR HYPERNATREMIA - ELECTROLYTE AND
276.9
FLUID DISORDERS NOT ELSEWHERE CLASSIFIED
278.01 MORBID OBESITY
290.0 - SENILE DEMENTIA UNCOMPLICATED - UNSPECIFIED TYPE
295.95 SCHIZOPHRENIA IN REMISSION
BIPOLAR I DISORDER, SINGLE MANIC EPISODE, UNSPECIFIED - BIPOLAR I
296.00 DISORDER, SINGLE MANIC EPISODE, IN PARTIAL OR UNSPECIFIED
296.05
REMISSION
MANIC AFFECTIVE DISORDER RECURRENT EPISODE UNSPECIFIED
296.10 DEGREE - MANIC AFFECTIVE DISORDER RECURRENT EPISODE IN
296.15
PARTIAL OR UNSPECIFIED REMISSION
MAJOR DEPRESSIVE AFFECTIVE DISORDER SINGLE EPISODE
296.20 UNSPECIFIED DEGREE - MAJOR DEPRESSIVE AFFECTIVE DISORDER
296.25
SINGLE EPISODE IN PARTIAL OR UNSPECIFIED REMISSION
MAJOR DEPRESSIVE AFFECTIVE DISORDER RECURRENT EPISODE
296.30 UNSPECIFIED DEGREE - MAJOR DEPRESSIVE AFFECTIVE DISORDER
296.35
RECURRENT EPISODE IN PARTIAL OR UNSPECIFIED REMISSION
BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) MANIC,
296.40 UNSPECIFIED - BIPOLAR I DISORDER, MOST RECENT EPISODE (OR
296.45
CURRENT) MANIC, IN PARTIAL OR UNSPECIFIED REMISSION
BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT)
296.50 - DEPRESSED, UNSPECIFIED - BIPOLAR I DISORDER, MOST RECENT
296.55 EPISODE (OR CURRENT) DEPRESSED, IN PARTIAL OR UNSPECIFIED
REMISSION
BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) MIXED,
296.60 UNSPECIFIED - BIPOLAR I DISORDER, MOST RECENT EPISODE (OR
296.65
CURRENT) MIXED, IN PARTIAL OR UNSPECIFIED REMISSION
296.80 BIPOLAR DISORDER, UNSPECIFIED - ATYPICAL DEPRESSIVE DISORDER
296.82
296.89 OTHER AND UNSPECIFIED BIPOLAR DISORDERS, OTHER
296.90 UNSPECIFIED EPISODIC MOOD DISORDER
296.99 OTHER SPECIFIED EPISODIC MOOD DISORDER
297.0 - PARANOID STATE SIMPLE - OTHER SPECIFIED PERVASIVE
299.81 DEVELOPMENTAL DISORDERS, RESIDUAL STATE
300.00 ANXIETY STATE UNSPECIFIED - HYSTERIA UNSPECIFIED
300.10
300.20 PHOBIA UNSPECIFIED - OTHER ISOLATED OR SPECIFIC PHOBIAS
300.29
304.01 - OPIOID TYPE DEPENDENCE CONTINUOUS USE - UNSPECIFIED DRUG
304.93 DEPENDENCE IN REMISSION
305.00 - NONDEPENDENT ALCOHOL ABUSE UNSPECIFIED DRINKING BEHAVIOR 305.02 NONDEPENDENT ALCOHOL ABUSE EPISODIC DRINKING BEHAVIOR
305.20 - NONDEPENDENT CANNABIS ABUSE UNSPECIFIED USE - NONDEPENDENT
305.22 CANNABIS ABUSE EPISODIC USE
305.30 - NONDEPENDENT HALLUCINOGEN ABUSE UNSPECIFIED USE 305.32 NONDEPENDENT HALLUCINOGEN ABUSE EPISODIC USE
305.40 - SEDATIVE, HYPNOTIC OR ANXIOLYTIC ABUSE, UNSPECIFIED 305.42 SEDATIVE, HYPNOTIC OR ANXIOLYTIC ABUSE, EPISODIC
305.50 - NONDEPENDENT OPIOID ABUSE UNSPECIFIED USE - NONDEPENDENT
305.52 OPIOID ABUSE EPISODIC USE
305.60 - NONDEPENDENT COCAINE ABUSE UNSPECIFIED USE - NONDEPENDENT
305.62 COCAINE ABUSE EPISODIC USE
NONDEPENDENT AMPHETAMINE OR RELATED ACTING
305.70 - SYMPATHOMIMETIC ABUSE UNSPECIFIED USE - NONDEPENDENT
305.72 AMPHETAMINE OR RELATED ACTING SYMPATHOMIMETIC ABUSE
EPISODIC USE
305.80 - NONDEPENDENT ANTIDEPRESSANT TYPE ABUSE UNSPECIFIED USE 305.82 NONDEPENDENT ANTIDEPRESSANT TYPE ABUSE EPISODIC USE
308.3
OTHER ACUTE REACTIONS TO STRESS
319
UNSPECIFIED INTELLECTUAL DISABILITIES
324.0
INTRACRANIAL ABSCESS
331.0
345.00 345.91
391.0 391.2
394.0 397.9
401.0
402.00 402.01
402.10 402.11
402.90 402.91
404.00 404.03
404.11 404.13
404.91 404.93
405.01 405.91
410.00 410.02
410.10 410.12
410.20 410.22
410.30 410.32
ALZHEIMER'S DISEASE
GENERALIZED NONCONVULSIVE EPILEPSY WITHOUT INTRACTABLE
EPILEPSY - EPILEPSY UNSPECIFIED WITH INTRACTABLE EPILEPSY
ACUTE RHEUMATIC PERICARDITIS - ACUTE RHEUMATIC MYOCARDITIS
MITRAL STENOSIS - RHEUMATIC DISEASES OF ENDOCARDIUM VALVE
UNSPECIFIED
MALIGNANT ESSENTIAL HYPERTENSION
MALIGNANT HYPERTENSIVE HEART DISEASE WITHOUT HEART FAILURE
- MALIGNANT HYPERTENSIVE HEART DISEASE WITH HEART FAILURE
BENIGN HYPERTENSIVE HEART DISEASE WITHOUT HEART FAILURE BENIGN HYPERTENSIVE HEART DISEASE WITH HEART FAILURE
UNSPECIFIED HYPERTENSIVE HEART DISEASE WITHOUT HEART
FAILURE - UNSPECIFIED HYPERTENSIVE HEART DISEASE WITH HEART
FAILURE
HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, MALIGNANT,
WITHOUT HEART FAILURE AND WITH CHRONIC KIDNEY DISEASE STAGE
I THROUGH STAGE IV, OR UNSPECIFIED - HYPERTENSIVE HEART AND
CHRONIC KIDNEY DISEASE, MALIGNANT, WITH HEART FAILURE AND
WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL
DISEASE
HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, BENIGN, WITH
HEART FAILURE AND WITH CHRONIC KIDNEY DISEASE STAGE I
THROUGH STAGE IV, OR UNSPECIFIED - HYPERTENSIVE HEART AND
CHRONIC KIDNEY DISEASE, BENIGN, WITH HEART FAILURE AND
CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE
HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, UNSPECIFIED,
WITH HEART FAILURE AND WITH CHRONIC KIDNEY DISEASE STAGE I
THROUGH STAGE IV, OR UNSPECIFIED - HYPERTENSIVE HEART AND
CHRONIC KIDNEY DISEASE, UNSPECIFIED, WITH HEART FAILURE AND
CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE
MALIGNANT RENOVASCULAR HYPERTENSION - UNSPECIFIED
RENOVASCULAR HYPERTENSION
ACUTE MYOCARDIAL INFARCTION OF ANTEROLATERAL WALL EPISODE
OF CARE UNSPECIFIED - ACUTE MYOCARDIAL INFARCTION OF
ANTEROLATERAL WALL SUBSEQUENT EPISODE OF CARE
ACUTE MYOCARDIAL INFARCTION OF OTHER ANTERIOR WALL EPISODE
OF CARE UNSPECIFIED - ACUTE MYOCARDIAL INFARCTION OF OTHER
ANTERIOR WALL SUBSEQUENT EPISODE OF CARE
ACUTE MYOCARDIAL INFARCTION OF INFEROLATERAL WALL EPISODE
OF CARE UNSPECIFIED - ACUTE MYOCARDIAL INFARCTION OF
INFEROLATERAL WALL SUBSEQUENT EPISODE OF CARE
ACUTE MYOCARDIAL INFARCTION OF INFEROPOSTERIOR WALL
EPISODE OF CARE UNSPECIFIED - ACUTE MYOCARDIAL INFARCTION OF
INFEROPOSTERIOR WALL SUBSEQUENT EPISODE OF CARE
ACUTE MYOCARDIAL INFARCTION OF OTHER INFERIOR WALL EPISODE
410.40 OF CARE UNSPECIFIED - ACUTE MYOCARDIAL INFARCTION OF OTHER
410.42
INFERIOR WALL SUBSEQUENT EPISODE OF CARE
ACUTE MYOCARDIAL INFARCTION OF OTHER LATERAL WALL EPISODE
410.50 OF CARE UNSPECIFIED - ACUTE MYOCARDIAL INFARCTION OF OTHER
410.52
LATERAL WALL SUBSEQUENT EPISODE OF CARE
410.60 - TRUE POSTERIOR WALL INFARCTION EPISODE OF CARE UNSPECIFIED 410.62 TRUE POSTERIOR WALL INFARCTION SUBSEQUENT EPISODE OF CARE
410.70 - SUBENDOCARDIAL INFARCTION EPISODE OF CARE UNSPECIFIED 410.72 SUBENDOCARDIAL INFARCTION SUBSEQUENT EPISODE OF CARE
ACUTE MYOCARDIAL INFARCTION OF OTHER SPECIFIED SITES EPISODE
410.80 OF CARE UNSPECIFIED - ACUTE MYOCARDIAL INFARCTION OF OTHER
410.82
SPECIFIED SITES SUBSEQUENT EPISODE OF CARE
ACUTE MYOCARDIAL INFARCTION OF UNSPECIFIED SITE EPISODE OF
410.90 CARE UNSPECIFIED - ACUTE MYOCARDIAL INFARCTION OF
410.92
UNSPECIFIED SITE SUBSEQUENT EPISODE OF CARE
411.0 - POSTMYOCARDIAL INFARCTION SYNDROME - INTERMEDIATE
411.1
CORONARY SYNDROME
411.81 ACUTE CORONARY OCCLUSION WITHOUT MYOCARDIAL INFARCTION
OTHER ACUTE AND SUBACUTE FORMS OF ISCHEMIC HEART DISEASE
411.89
OTHER
413.0 ANGINA DECUBITUS - PRINZMETAL ANGINA
413.1
413.9
OTHER AND UNSPECIFIED ANGINA PECTORIS
CORONARY ATHEROSCLEROSIS OF UNSPECIFIED TYPE OF VESSEL
414.00 NATIVE OR GRAFT - CORONARY ATHEROSCLEROSIS OF ARTERY
414.04
BYPASS GRAFT
CORONARY ATHEROSCLEROSIS OF NATIVE CORONARY ARTERY OF
414.06
TRANSPLANTED HEART
CORONARY ATHEROSCLEROSIS OF BYPASS GRAFT (ARTERY) (VEIN) OF
414.07
TRANSPLANTED HEART
414.10 ANEURYSM OF HEART (WALL) - DISSECTION OF CORONARY ARTERY
414.12
414.19 OTHER ANEURYSM OF HEART
414.4
CORONARY ATHEROSCLEROSIS DUE TO CALCIFIED CORONARY LESION
414.8 - OTHER SPECIFIED FORMS OF CHRONIC ISCHEMIC HEART DISEASE 414.9
CHRONIC ISCHEMIC HEART DISEASE UNSPECIFIED
415.0
ACUTE COR PULMONALE
415.13 SADDLE EMBOLUS OF PULMONARY ARTERY
416.0 - PRIMARY PULMONARY HYPERTENSION - CHRONIC PULMONARY HEART
416.9
DISEASE UNSPECIFIED
420.0
ACUTE PERICARDITIS IN DISEASES CLASSIFIED ELSEWHERE
420.90 ACUTE PERICARDITIS UNSPECIFIED - ACUTE IDIOPATHIC PERICARDITIS
420.91
420.99
421.0 421.1
421.9
422.0
422.90 422.93
422.99
423.0 423.2
423.8 423.9
424.0 424.3
424.90 424.91
424.99
425.0 425.9
426.0 427.69
427.81
427.89
428.0 428.9
430 - 431
432.0 432.1
432.9
433.00 433.01
433.10 433.11
433.20 433.21
433.30 433.31
OTHER ACUTE PERICARDITIS
ACUTE AND SUBACUTE BACTERIAL ENDOCARDITIS - ACUTE AND
SUBACUTE INFECTIVE ENDOCARDITIS IN DISEASES CLASSIFIED
ELSEWHERE
ACUTE ENDOCARDITIS UNSPECIFIED
ACUTE MYOCARDITIS IN DISEASES CLASSIFIED ELSEWHERE
ACUTE MYOCARDITIS UNSPECIFIED - TOXIC MYOCARDITIS
OTHER ACUTE MYOCARDITIS
HEMOPERICARDIUM - CONSTRICTIVE PERICARDITIS
OTHER SPECIFIED DISEASES OF PERICARDIUM - UNSPECIFIED DISEASE
OF PERICARDIUM
MITRAL VALVE DISORDERS - PULMONARY VALVE DISORDERS
ENDOCARDITIS VALVE UNSPECIFIED UNSPECIFIED CAUSE ENDOCARDITIS IN DISEASES CLASSIFIED ELSEWHERE
OTHER ENDOCARDITIS VALVE UNSPECIFIED
ENDOMYOCARDIAL FIBROSIS - SECONDARY CARDIOMYOPATHY
UNSPECIFIED
ATRIOVENTRICULAR BLOCK COMPLETE - OTHER PREMATURE BEATS
SINOATRIAL NODE DYSFUNCTION
OTHER SPECIFIED CARDIAC DYSRHYTHMIAS
CONGESTIVE HEART FAILURE UNSPECIFIED - HEART FAILURE
UNSPECIFIED
SUBARACHNOID HEMORRHAGE - INTRACEREBRAL HEMORRHAGE
NONTRAUMATIC EXTRADURAL HEMORRHAGE - SUBDURAL
HEMORRHAGE
UNSPECIFIED INTRACRANIAL HEMORRHAGE
OCCLUSION AND STENOSIS OF BASILAR ARTERY WITHOUT CEREBRAL
INFARCTION - OCCLUSION AND STENOSIS OF BASILAR ARTERY WITH
CEREBRAL INFARCTION
OCCLUSION AND STENOSIS OF CAROTID ARTERY WITHOUT CEREBRAL
INFARCTION - OCCLUSION AND STENOSIS OF CAROTID ARTERY WITH
CEREBRAL INFARCTION
OCCLUSION AND STENOSIS OF VERTEBRAL ARTERY WITHOUT
CEREBRAL INFARCTION - OCCLUSION AND STENOSIS OF VERTEBRAL
ARTERY WITH CEREBRAL INFARCTION
OCCLUSION AND STENOSIS OF MULTIPLE AND BILATERAL
PRECEREBRAL ARTERIES WITHOUT CEREBRAL INFARCTION OCCLUSION AND STENOSIS OF MULTIPLE AND BILATERAL
PRECEREBRAL ARTERIES WITH CEREBRAL INFARCTION
433.80 433.81
433.90 433.91
434.00 434.01
434.10 434.11
434.90 434.91
435.0 435.3
435.8 435.9
436
437.0 437.9
490 - 496
500 - 505
506.0 506.4
506.9
508.0 508.1
508.2
508.8 508.9
OCCLUSION AND STENOSIS OF OTHER SPECIFIED PRECEREBRAL
ARTERY WITHOUT CEREBRAL INFARCTION - OCCLUSION AND STENOSIS
OF OTHER SPECIFIED PRECEREBRAL ARTERY WITH CEREBRAL
INFARCTION
OCCLUSION AND STENOSIS OF UNSPECIFIED PRECEREBRAL ARTERY
WITHOUT CEREBRAL INFARCTION - OCCLUSION AND STENOSIS OF
UNSPECIFIED PRECEREBRAL ARTERY WITH CEREBRAL INFARCTION
CEREBRAL THROMBOSIS WITHOUT CEREBRAL INFARCTION - CEREBRAL
THROMBOSIS WITH CEREBRAL INFARCTION
CEREBRAL EMBOLISM WITHOUT CEREBRAL INFARCTION - CEREBRAL
EMBOLISM WITH CEREBRAL INFARCTION
CEREBRAL ARTERY OCCLUSION UNSPECIFIED WITHOUT CEREBRAL
INFARCTION - CEREBRAL ARTERY OCCLUSION UNSPECIFIED WITH
CEREBRAL INFARCTION
BASILAR ARTERY SYNDROME - VERTEBROBASILAR ARTERY
SYNDROME
OTHER SPECIFIED TRANSIENT CEREBRAL ISCHEMIAS - UNSPECIFIED
TRANSIENT CEREBRAL ISCHEMIA
ACUTE BUT ILL-DEFINED CEREBROVASCULAR DISEASE
CEREBRAL ATHEROSCLEROSIS - UNSPECIFIED CEREBROVASCULAR
DISEASE
BRONCHITIS NOT SPECIFIED AS ACUTE OR CHRONIC - CHRONIC AIRWAY
OBSTRUCTION NOT ELSEWHERE CLASSIFIED
COAL WORKERS' PNEUMOCONIOSIS - PNEUMOCONIOSIS UNSPECIFIED
BRONCHITIS AND PNEUMONITIS DUE TO FUMES AND VAPORS CHRONIC RESPIRATORY CONDITIONS DUE TO FUMES AND VAPORS
UNSPECIFIED RESPIRATORY CONDITIONS DUE TO FUMES AND VAPORS
ACUTE PULMONARY MANIFESTATIONS DUE TO RADIATION - CHRONIC
AND OTHER PULMONARY MANIFESTATIONS DUE TO RADIATION
RESPIRATORY CONDITIONS DUE TO SMOKE INHALATION
RESPIRATORY CONDITIONS DUE TO OTHER SPECIFIED EXTERNAL
AGENTS - RESPIRATORY CONDITIONS DUE TO UNSPECIFIED EXTERNAL
AGENT
EMPYEMA WITH FISTULA
EMPYEMA WITHOUT FISTULA
SPONTANEOUS TENSION PNEUMOTHORAX
PULMONARY COLLAPSE - ACUTE AND CHRONIC RESPIRATORY FAILURE
FOLLOWING TRAUMA AND SURGERY
ACUTE RESPIRATORY FAILURE - OTHER PULMONARY INSUFFICIENCY
NOT ELSEWHERE CLASSIFIED
ACUTE AND SUBACUTE NECROSIS OF LIVER - OTHER CHRONIC
NONALCOHOLIC LIVER DISEASE
510.0
510.9
512.0
518.0 518.53
518.81 518.82
570 571.8
572.0 ABSCESS OF LIVER - OTHER SEQUELAE OF CHRONIC LIVER DISEASE
572.8
584.5 586
780.1
780.31
780.33
780.39
785.50 785.59
786.1
995.0 995.4
995.60 995.69
ACUTE KIDNEY FAILURE WITH LESION OF TUBULAR NECROSIS - RENAL
FAILURE UNSPECIFIED
HALLUCINATIONS
FEBRILE CONVULSIONS (SIMPLE), UNSPECIFIED
POST TRAUMATIC SEIZURES
OTHER CONVULSIONS
SHOCK UNSPECIFIED - OTHER SHOCK WITHOUT TRAUMA
STRIDOR
OTHER ANAPHYLACTIC REACTION - SHOCK DUE TO ANESTHESIA NOT
ELSEWHERE CLASSIFIED
ANAPHYLACTIC REACTION DUE TO UNSPECIFIED FOOD ANAPHYLACTIC REACTION DUE TO OTHER SPECIFIED FOOD
UNSPECIFIED COMPLICATION OF PROCEDURE NOT ELSEWHERE
998.9
CLASSIFIED
V44.0
TRACHEOSTOMY STATUS
V58.83* ENCOUNTER FOR THERAPEUTIC DRUG MONITORING
Group 1 Medical Necessity ICD-9 Codes Asterisk Explanation: *Use V58.83 solely for
propofol use, when it is warranted and there is no other ICD-9-CM to describe the
condition of the patient. Report this in conjunction with the verbiage, “propofol” in the
narrative section of the claim.
ICD-9 Codes that DO NOT Support Medical Necessity
Paragraph: All those not listed under the “ICD-9 Codes that Support Medical Necessity”
section of this policy.
N/A
General Information
Associated Information
Documentation Guidelines
1. All documentation must be maintained in the patient’s medical record and available to
the contractor upon request.
2. Every page of the record must be legible and include appropriate patient identification
information (e.g., complete name, dates of service(s)). The record must include the
physician or non-physician practitioner responsible for and providing the care of the
patient.
3. The submitted medical record should support the use of the selected ICD-9-CM code(s).
The submitted CPT/HCPCS code should describe the service performed.
4. The medical record documentation must support the medical necessity of the services as
directed in this policy.
The following Documentation Requirements are pertinent to any and all MAC services in
general, regardless of the procedure performed or the anesthesia drug(s) administered.
Clear and complete documentation is a factor in the provision of quality care. Supportive
documentation is the responsibility of the anesthetist, and mandatory for Medicare coverage and
reimbursement. While anesthesia care is a continuum, it is viewed as consisting of preanesthesia,
perianesthesia and postanesthesia components. Monitored anesthesia care (MAC) must be
documented to include the following:
I. Pre-anesthesia evaluation
A.
B.
C.
D.
E.
Patient interview to include medical history, anesthesia history, medication history
Appropriate physical exam
Review of objective diagnostic data (e.g., laboratory, ECG, X-ray)
Assignment of physical status (e.g., ASA physical status protocols)
Formulation and discussion of an anesthesia plan with the patient (and/or responsible
adult) and patient's attending surgeon
II. Perianesthesia (time-based record of events)
A. Immediate review prior to initiation of anesthetic procedure:
1. Patient re-evaluation
2. Check of equipment, drugs, gas supply
B. Monitoring of the patient
1. Qualified anesthesia personnel shall be present in the room throughout MAC
2. The patient's oxygenation, ventilation, circulation, and temperature shall be
continually evaluated.
C. Amounts of all drugs and agents used, and times given
D. The type and amounts of any/all intravenous fluids used, including blood and blood
products, and times given
E. The technique(s) used
F. All unusual events during the anesthesia-monitoring period
G. Status of patient at conclusion of anesthesia and procedure
III. Postanesthesia
A. Patient evaluation on admission and discharge from postanesthesia
B.
C.
D.
E.
F.
A time-based record of vital signs and level of consciousness
All drugs administered and their dosages
Types and amounts of intravenous fluids administered
Any unusual events including postanesthesia or postprocedural complications
Postanesthesia visits and any follow-up prescribed
When reporting MAC for one of the procedures listed in the "CPT/HCPCS Codes" section of
this policy or for propofol, in conjunction with a CPT code from Appendix G of CPT or a
procedure that does not usually require MAC, the presence of an underlying condition alone, as
reported by an ICD-9 code, may not be sufficient evidence that MAC is necessary. The medical
condition must be significant enough to impact on the need to provide MAC and be clearly
reflected in the medical record. All services required to fulfill the definition of the service for
MAC must be performed when this service is billed for one of the CPT codes or for propofol.
Services other than for propofol that usually do not require MAC and are not supported by an
underlying condition represented in the "ICD-9 Codes That Support Medical Necessity" section
of this policy, may be reviewed on an individual consideration basis. All supporting
documentation must be forwarded to the contractor upon request.
ICD-9 V58.83 (Encounter for therapeutic drug monitoring) should be used when patient
provided MAC monitoring secondary, or integral, to the use of propofol. Include the verbiage,
“propofol” in the narrative field of the claim.
Appendices
N/A
Utilization Guidelines
In accordance with CMS Ruling 95-1(V), utilization of this service(s) should be consistent with
locally acceptable standards of practice.
Sources of Information and Basis for Decision
Contractor is not responsible for the continued viability of websites listed.
AANA-ASA Joint Statement Regarding Propofol Administration April 14, 2004
American Medical Association, Current Procedural Terminology; CPT 2000
American Society of Gastrointestinal Endoscopy, publication #1016
ASA Position on Monitored Anesthesia Care (Approved by the ASA House of Delegates on
October 21, 1998), December; 1998 Vol. 62
Carrier Medical Director's Workgroup Template policy
Coursin DB, Maccioli GA, Murray MJ. Perioperative Medicine; Anesthesiology Clin North
America. Sept.;2000;18 (3).
Deng Xin-sheng, Simpson VJ, Deitrich RA. Department of Pharmacology, Nitric oxide and
Propofol University of Colorado Health Sciences Center, Denver, Colorado, USA 80262
Heine J, Jaegar A, Osthaus N, et al. Anaesthesia with propofol decreases FMLP-induced
neutrophil respiratory burst but not phagocytosis compared with isoflurane; British Journal of
Anaesthesia 2000; 85(3) 424-430.
Leffler TM, Propofol for sedation in the endoscopy setting: nursing considerations for patient
care; Gastroenterol Nurs. 2004 Jul-Aug 27; (4):176-80
Medicode ICD-9, 1999
Practice Guidelines For Sedation And Analgesia By Non-Anesthesiologists, (Approved By The
House Of Delegates On October 25, 1995, And Last Amended On October 17, 2001) An
Updated Report By The American Society Of Anesthesiologists Task Force On Sedation And
Analgesia By Non-Anesthesiologists
Practice Guidelines for Acute Pain Management in the Perioperative Setting (Approved by the
House of Delegates on October 16, 1994, and last amended on October 15, 2003), Developed by
the American Society of Anesthesiologists Task Force on Acute Pain Management
The American Society of Anesthesiologists, Inc.; Practice Guidelines
Tung A. New anesthesia techniques; Thorac Surg Clin. 2005 Feb15;(1):27-38.
Other Contractors' Policies
Contractor Medical Directors
Advisory Committee Meeting Notes
This policy does not reflect the sole opinion of the contractor or Contractor Medical Directors.
Although the final decision rests with the contractor, this policy was developed in cooperation
with advisory groups that include representatives from Anesthesiology.
CAC/IAC Distribution: 04/01/2008
CAC Distribution: 05/15/2012
Revision History Information
Please note: Most Revision History entries effective on or before 01/24/2013 display with a
Revision History Number of "R1" at the bottom of this table. However, there may be LCDs
where these entries will display as a separate and distinct row.
Revision
History
Date
Revision
History
Number
08/21/2014 R3
11/15/2012 R2
Revision History Explanation
LCD updated on 08-13-2014 for
administrative purposes only. No content
changes have been made to this LCD
version.
Reason(s) for Change
•
Other
(Administrative
purposes.)
•
Other (CPT/ HCPCS
codes formerly in
ranges now listed as
separate codes.)
•
Coverage Change
(actual change in
medical parameters)
LCD revised to remove procedure code
ranges and individually list each applicable
CPT/HCPCS code.
09/27/2012 L27489 Final LCD posted for
notice and will become effective for dates
of service on and after 11/15/2012.
05/15/2012 DL27489 Draft LCD posted for
comment.
04/02/2012 L27489 LCD revised to reflect
contractor name change from Highmark
Medicare Services to Novitas Solutions,
Inc.
11/15/2012 R1
10/01/2011 L27489 LCD revised effective
10/01/2011 to reflect the ICD-9-CM
update. The following codes have been
deleted: 425.1 and 518.5. The following
codes have been added: 294.20, 294.21,
414.4, 415.13, 425.11, 425.18, 508.2,
518.51, 518.52, and 518.53. The following
code descriptors have been revised: 319,
995.0, and 995.60-995.69. Some of these
changes may be within code ranges.
02/21/2011 L27489 Per Change Request
7135, this LCD is effective for dates of
service on and after 02/21/2011 for those
providers in the states of Delaware,
Maryland, New Jersey, Pennsylvania and
the District of Columbia serviced by
Wisconsin Physicians Service (WPS),
contractor number 52280, that are being
transitioned to Highmark Medicare
Services, contractor number 12901,
effective 02/21/2011.
10/27/2010 L27489 LCD revised effective
10/27/2010. The following changes are per
the annual ICD-9-CM code update: ICD-9CM code 276.6 removed for dates of
service on and after 10/01/2010. ICD-9CM codes 276.61, 276.69 and 780.33
added for coverage effective for dates of
service on and after 10/01/2010. Some of
these changes are in code ranges.
10/08/2009 L27489 LCD revised effective
10/09/2009. LCD revised due to ICD-9CM annual updates. The following ICD-9CM code changes are effective 10/01/2009.
These changes are within code ranges.
Revised code descriptors 572.2, 584.5,
584.6, 584.7, 584.8, 584.9. Added new
codes: 416.2, 995.24.
12/12/2008 L27489 LCD effective
12/12/2008 for Pennsylvania Part B. LCD
is now effective for DC Part A and DCMA
Part B; Delaware Part A and Part B;
Maryland Part A and Part B; New Jersey
Part A and Part B; Pennsylvania Part A and
Part B.
11/14/2008 L27489 LCD effective
11/14/2008 for New Jersey Part B and
Delaware Part A. LCD is now effective for
DC Part A and DCMA Part B; Delaware
Part A and Delaware Part B; Maryland Part
A and Maryland Part B; New Jersey Part A
and New Jersey Part B; Pennsylvania Part
A.
09/24/2008 L27489 The following ICD-9
code changes will be effective 10/01/2008
due to ICD-9-CM annual updates. Revised
code descriptor for code 038.11. Added
new codes 038.12 and 249.00-249.91.
Some of these changes are within a code
range. LCD revision effective 09/25/2008.
08/29/2008 L27489 LCD effective
09/01/2008 for New Jersey Part A.
Effective 09/01/2008, New Jersey Part A
will be added to the other jurisdictions
already effective: DC Part A and DCMA
Part B; Maryland Part A and Maryland Part
B; Pennsylvania Part A; and Delaware Part
B.
08/01/2008 L27489 LCD effective
08/01/2008 for DC Part A, Maryland Part
A, and Pennsylvania Part A. LCD is now
effective for DC Part A and DCMA Part B;
Maryland Part A and Maryland Part B;
Pennsylvania Part A; and Delaware Part B.
05/23/2008 L27489 Original LCD posted
for notice. LCD to become effective
07/11/2008 for Maryland Part B, DCMA
Part B and Delaware Part B.
04/01/2008 Draft J12-D17 Original LCD
posted for comment.
Associated Documents
Attachments
N/A
Related Local Coverage Documents
N/A
Related National Coverage Documents
N/A
Public Version(s)
Updated on 08/13/2014 with effective dates 08/21/2014 - N/A
Updated on 03/23/2013 with effective dates 11/15/2012 - 08/20/2014
Updated on 10/04/2012 with effective dates 11/15/2012 - N/A