Description:
The administration of anesthesia is appropriate when rendered by or under the responsible supervision of a physician. These services may include, but are not limited to, general, regional, supplementation of local anesthesia or other supportive services in order to afford the patient the anesthesia care deemed optimal by the anesthesiologist during any procedure. These services include the usual pre-operative and post-operative visits, the anesthesia care during the procedure, the administration of fluids and/or blood and the usual monitoring services (e.g., ECG, temperature, blood pressure, optometry, capnography and mass spectrometry). Other forms of monitoring (e.g., intra-arterial, central venous and Swan-Ganz) are not included.

Policy:
Benefits will be provided when a physician or certified registered nurse anesthetist (CRNA) who customarily bills for his/her services administers anesthesia. Benefits are not provided when the attending or assisting physician, with the exception of regional anesthesia administered during delivery, administers anesthesia.

Benefits will be provided as a secondary surgery for introduction of an anesthetic agent by the delivering OB physician or his assistant to accomplish a nerve block (e.g., epidural, caudal). As such, reimbursement will be limited to 50 percent of the allowable charge for the anesthesia services of such physician.

Epidural anesthesia for maternity is reimbursed as a global allowance with no consideration of time units. Generally, the practitioner who inserts the epidural needle will file for the total service using modifier AA. If, however, an arrangement is made between the physician and the CRNA to both bill for the epidural, the physician should bill either modifer QK or QY, and the CRNA should bill with modifer QX. To report obstetrical epidural administration, physicians should file code 01967 for normal delivery. If cesarean section is performed, both codes 01967 and 01968 should be reported. This code should not be reported for "standing by" if the patient elects natural childbirth and no epidural is performed.

When anesthesia services are provided with a non-covered service, the physician's charge for the anesthesia is also not covered, with the exception of general anesthesia for dental surgical procedures that are covered under a separate dental contract.

Anesthesia time begins when the anesthesiologist begins to prepare the patient for the induction of anesthesia in the operating room or in an equivalent area and ends when the patient may be safely placed under post-operative supervision.

All claims filed with CPT anesthesia codes 00100 – 01999 must have one of the following modifiers: AA, AD, QX, QY or QZ. The definitions of the modifiers reflect whether an anesthesia service was performed under the supervision of an anesthesiologist or a Certified Registered Nurse Anesthetist. A complete list of modifiers is below:

Anesthesiologist Modifiers:
AA — Anesthesia services performed personally by anesthesiologist.

AD — Medical supervision by a physician; more than four concurrent anesthesia procedures.

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

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

CRNA Modifiers:
QX — CRNA service: With medical direction by a physician.

QZ — CRNA service: Without medical direction by a physician.

Benefits are not provided for:

Separate benefits are not provided for the following if in conjunction with general anesthesia:

1. Pre-operative anesthesia consultation
2. Transesophageal cardiography (CPT 93312-93318) 

Emergency intubation (CPT 31500)

Stand-by Anesthesia:
Benefits are provided if the anesthesiologist provides all of the personal patient care normally provided when anesthesia is administered (e.g., examines patient, connects monitoring lines, personally monitors patients during operative procedure) except for actually administering anesthesia but stands by to administer if required. The anesthesiologist may be reimbursed for both the procedure and time. If the anesthesiologist fails to provide the full range of patient services while "standing by," no reimbursement should be provided for any services rendered unless approved by the medical staff.

Claims should be filed for stand-by anesthesia using the appropriate anesthesia code, anesthesia modifier and time units.

Monitored Anesthesia Care
QS — Monitored anesthesia care service. (Must appear in the 2nd modifier field)

G8 — Monitored anesthesia care (MAC) for deep complex, complicated or markedly invasive surgical procedure. (Must appear in the 2nd modifier field)

G9 — Monitored anesthesia care for patient who has history of severe cardiopulmonary condition. (Must appear in the 2nd modifier field).

One of the current requirements is that the physician must participate in the most demanding procedures of the anesthesia plan, including induction and emergence. The current requirement was included at a time when general anesthesia was the usual mode of practice for anesthesia services. However, since that time, other types of anesthesia care, such as regional anesthetics and monitored anesthesia care, have become more common. The clarification is that the physician must participate in the most demanding procedures of the anesthesia plan, including, if applicable, induction and emergence.

Payment may be made for modifiers QS, G8 and G9 only if personally performed by a physician (modifier AA).

Modifier AD
Modifier AD denotes supervision of more than 4 CRNAs. Reimbursement was based on 3.0 base units. No additional monies are recognized for time.

Special Procedures:
If a Swan-Ganz catheter, central venous pressure (CVP) and arterial lines are billed in conjunction with the administration of anesthesia, the reimbursement will be 50 percent of the allowance for the catheterization and/or insertion of arterial lines and 100 percent of the allowance for the administration of anesthesia. However, if billed without administration of anesthesia, allow Swan-Ganz at 100 percent and CVP and arterial lines at 50 percent. Most routine gastrointestinal endocopic procedures DO NOT require general anesthesia. Therefore, general anesthesia services are considered not medically necessary. Anesthesia services may be considered MEDICALLY NECESSARY during gastrointestinal endoscopy, colonoscopy and sigmoidoscopy procedures in any of the following situations:

• Prolonged or therapeutic endoscopic procedure requiring deep sedation
• A patient has a history of or anticipated intolerance to standard sedatives (e.g., patient on chronic narcotics or benzodiazepines, or has a neuropsychiatric disorder)
• A patient who is at increased risk for complication due to severe co-morbidity
• A patient over the age of 70
• Pediatric patients (age 15 and under)
• Patients who are pregnant
• A patient who has a history of drug or alcohol abuse
• Uncooperative or acutely agitated patients (e.g., dementia, organic brain disease, senile dementia)
• A patient who has increased risk for airway obstruction due to anatomic variant including any of the following:
  • History of previous problems with anesthesia or sedation
  • History of stridor or sleep apnea
  • Dysmorphic facial features, such as Pierre-Robin syndrome or trisomy-21
  • Presence of oral abnormalities including, but not limited to, a small oral opening (less than 3 cm in an adult), high arched palate, macroglossia, tonsillar hypertrophy or a non-visable uvula neck extension, decreased hyoid-ment distance (less than 3 cm in an adult), neck mass, cervical spine disease or trauma, tracheal deviation or advanced rheumatoid arthritis
  • Jaw abnormalities including, but not limited to, micrognathia, retrognathia, trismus or significant malocculusion.

If the Member does not meet the above criteria, there is no anesthesia reimbursement allowed for endoscopic, colonoscopy or sigmoidoscopy procedures.

When a claim for anesthesia is filed with an individual consideration (IC) or a not-otherwise classified (NOC) procedure code and the surgery claim has already been processed, the claim processor may pay the NOC or IC anesthesia code with the appropriate anesthesia code allowance that corresponds with the code used for the surgery claim.

Anesthesia Risk Factor:
There are three modifiers that are acceptable for anesthesiologists or nurse anesthetists to file indicating they have added time limits when the physical status of the patient presented a serious health risk. These modifiers must be placed in the second modifier field of the claim form.

NOTE: Risk factors will only be paid if the physician (modifier AA on the primary anesthesia code) administers the anesthesia personally. There will be no separate reimbursement for risk factors for CRNAs or anesthesiologist supervision of CRNAs, even if reported separately.

Modifiers:
P-3: One time unit may be added when a patient has a severe systemic disease, such as uncontrolled diabetes or hypertension requiring medication.
P-4: Two time units may be added when a patient has a severe systemic disease that is a constant threat to life, such as severe respiratory or cardiac disease.
P-5: Three time units may be added when the patient is not expected to survive for 24 hours with or without the operation, such as multiple severe trauma or severe head injury.

NOTE: One hour for a patient whose physical status presented an additional health risk.

Procedure code used for a hernia repair:

00830AAP3; Days/Visits 5
Four units for one hour of anesthesia and one extra unit for risk factor

Qualifying Circumstances:
Many anesthesia services are provided under particularly difficult circumstances, depending on factors, such as extraordinary condition of patient, notable operative conditions and/or unusual risk factors. These circumstances significantly impact on the character of the anesthesia service provided. These procedures would not be reported above but would be reported as additional procedures qualifying an anesthesia procedure or service.

Qualifying circumstances will only be paid if the physician (modifier AA on the primary anesthesia code) administers the anesthesia personally. There will be no separate reimbursement for risk factors for CRNAs or anesthesiologist supervision of CRNAs, even if reported separately.

Procedure Codes:
99100 — Anesthesia for patient of extreme age, under one year and over 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).*

Procedure 99140 is normally considered an integral component of the administration of anesthesia. Records may be submitted to retrospective medical review documenting special extenuating circumstances for payment.

Moderate Conscious Sedation 99151-99157
Sedation with or without analgesia (conscious sedation) is used to achieve a medically controlled state of depressed consciousness while maintaining the patient's airway, protective reflexes and ability to respond to stimulation or verbal commands. Conscious sedation includes performance and documentation of pre- and post-sedation evaluations of the patient, administration of the sedation and/or analgesic agent(s) and monitoring of cardio respiratory function (i.e., pulse oximetry, cardio-respiratory monitor and blood pressure). The use of these codes requires the presence of an independent trained observer to assist the physician in monitoring the patient's level of consciousness and physiological status.

Anesthesia Base Units
Private Business utilizes the Medicare base units for procedures unless specifically addressed in the Private Business Administrative/Medical Policy Manual (i.e., epidurals will be not be reimbursed based on Medicare Base Units.)

Anesthesia Time Units
Anesthesia time units should be reported in minutes. The system will calculate the number of units for claims adjudication based on 15 minute increments, rounded to the nearest tenth (1/10th).

For example, 49 minutes would be calculated as follows:

49 minutes/15 increment = 3.266 units (3.266 would round to 3.3 time units.)

Medical Review:
Anesthesia claims should be forwarded to the retro review nurse for review when either of the following situations occurs:

• The anesthesia claim filed is for an unlisted anesthesia procedure and the surgeon’s claim is not yet on file for reference.
• The procedure filed is for possible cosmetic surgery.
• Exceptions to the above policies may be made by the Medical Director(s) based on documentation of medical necessity.

Rationale:
Location of the Procedure
The American Society of Anesthesiologists (ASA) has recommended that any location providing MAC have the capability of cardiopulmonary resuscitation and monitoring equipment.^8,9 In 2004, Fleisher and colleagues performed a retrospective claims data review on 564,267 outpatient surgical procedures: 360,780 at an outpatient department of a hospital, 175,288 at an ambulatory surgical center and 28,199 at a physician’s office.¹⁰ The rates of all-cause death, emergency department visits and inpatient admissions within seven days of the procedure were compared. The highest rates were seen among patients in the outpatient surgery department of the hospital, suggesting that patients evaluated to be at highest risk had their procedure in the location of lowest anesthesia risk. Multivariate analysis noted that increasing patient age, increasing procedural risk and increasing past medical history of inpatient admissions were all independently predictive of adverse outcome.

Use of Monitored Anesthesia Care in Endoscopy
An extensive review of the literature related to sedation for gastrointestinal (GI) endoscopy was published through the American Gastroenterological Association (AGA) Institute in 2007.¹¹ Portions of its review were relevant to this policy. The review recommended that use of an anesthesia professional should be strongly considered for ASA physical status 3 through 5 patients. They noted that other possible indications for an anesthesia specialist include patients with pregnancy, morbid obesity, neurologic or neuromuscular disorders, a history of alcohol or substance abuse and patients who are uncooperative or delirious. They also noted that endoscopic procedures that may require an anesthesia specialist include endoscopic retrograde cholangiopancreatography (ERCP), stent placement in the upper GI tract and complex therapeutic procedures, such as plication of the cardioesophageal junction. This review was used in formulating the initial conclusions of this policy.

Comparison of Sedative Agents Used in Endoscopy
Given the interest in use of propofol, additional details are provided concerning its use in GI endoscopy. A Cochrane systematic review by Singh and colleagues (updated in June 2011), summarized the results of RCTs comparing the use of propofol and traditional agents for use during colonoscopy.¹² This review encompassed and enlarged on a prior review by McQuaid and Laine, in 2008, which reviewed a broader set of studies of all randomized trials of any agents used for sedation for endoscopic procedures.¹³ The reviews come to largely similar conclusions, but certain comparisons were only performed in one or the other review.

The primary objective of the Cochrane review was to compare the relative effectiveness, patient acceptance and safety of propofol compared to traditional sedatives for patients undergoing colonoscopy.¹² The secondary objective was to synthesize the studies comparing propofol administration by anesthesiologists to that by non-anesthesiologists for sedation during colonoscopy. This review is an update of a previously published Cochrane systematic review in 2008. The literature search for the updated review was undertaken up to December 2010. The outcome measures of interest were technical performance of colonoscopy (recovery time, discharge time, procedure time), patient satisfaction, pain control and complication rates (cardio-respiratory events, colonic perforations and hospital admission rate after procedure and death).¹²

Twenty-two studies met the inclusion criteria for the primary objective in this updated review.¹² Eight (of 22) eligible RCTs evaluated propofol as a single agent, and seven trials were published in only abstract format, including the largest trial from 2000 (n = 7,286 patients), which reported on different rates of colonic perforation. Only one trial published in 2006 was a double-blinded RCT, where all patients as well as all those involved in administering the medications and assessing the outcomes were not aware of the intervention in different arms of the trial. The agents administered in the control arms across these trials included benzodiazepines alone (diazepam, midazolam) or a combination of a benzodiazepine and a narcotic (pethidine, fentanyl, remifentanil or alfentanil). One trial published in 2003 included only a narcotic (remifentanil) and all patients in the control arm of this study remained awake throughout the procedure. The dosage of the agents used varied across trials. The intended level of sedation when stated was defined in most studies as that needed for patients tolerance of the procedure. Many of the studies had a potential of moderate to high risk of bias, and combining data for some of the outcomes for meta-analysis was problematic. Most studies included only healthy outpatients.

Recovery time (reported in 11 studies; 776 patients) was shorter with propofol compared to the control arm (weighted mean difference [WMD]: -14.2 minutes; 95 percent confidence interval [CI]: -17.6, -10.8), with no significant heterogeneity (p = 0.41). Discharge time (seven studies; 542 patients) was also reported to be shorter with use of propofol (WMD: -20.9 minutes; 95 percent CI: -30.9, 10.8); however, there was significant heterogeneity between studies (p < 0.0001). There was higher patient satisfaction (10 studies, 819 patients) with use of propofol (odds ratio [OR]: for dissatisfaction 0.35; 95 percent CI: 0.23, 0.53). There was no difference in procedure time (nine studies; 736 patients) or complication rates. There was also no difference in pain control with non-patient controlled sedation (five studies; 396 patients) between propofol and the control arm (OR: 0.90; 95 percent CI: 0.58, 1.39).¹²

The Cochrane review found only one RCT, reported in abstract format, for the secondary objective, comparison of propofol administration by anesthesiologists (Group A) to that by endoscopists (Group B).¹² This RCT has subsequently been published by Poincloux and colleagues.¹⁴ Ninety adult patients (from a university center in France) undergoing colonoscopy were randomized into the above two groups. The goal of propofol administration by anesthesiologists was anesthesia and that by endoscopists was sedation. There was no difference in procedure time (16.7 minutes for Group A and 17.7 minutes for Group B) or patient satisfaction (average score on Visual Analog Scale, 90.8 vs. 89). A higher proportion of patients administered propofol by an anesthesiologist experienced hypoxia, but no patient required an intervention.¹⁴

There are numerous observational studies, and some of the representative publications are summarized here. Horiuchi et al. reported an observational study from Japan.¹⁵ Low-dose propofol was administered by nurses supervised by the endoscopist during diagnostic endoscopy. In this study, 10,662 patients were observed following receiving an age-dependent standard dose protocol of propofol, which was administered by bolus injection, with additional doses given when required for adequate sedation prior to esophagogastroduodenoscopy (EGD). The incidence of respiratory depression was the primary outcome for this study, and further measures of successful completion of the procedure and patient satisfaction were analyzed. Twenty-eight patients required transient supplemental oxygen supply, while none required mask or endotracheal intubation. All procedures were successful and 79.1 percent diagnostic EGDs were completed with a single bolus of propofol. The authors conclude that low-dose nurse-administered propofol sedation is safe when supervised by the endoscopist, and practical for diagnostic EGD. The study is limited by the lack of a comparison group. Patients with ASA classification 3 and 4 were excluded from the study, so these conclusions may not be generalized to that group.

Coté et al. reported another prospective observational study on 766 patients undergoing advanced endoscopic procedures, such as ERCP, endoscopic ultrasound and small-bowel enteroscopy, who received propofol.¹⁶ These procedures are notable for their duration and complexity compared to diagnostic EGD. The primary outcome measure was airway modifications (AM), with a comparison of defining characteristics of the group requiring at least one airway modification, such as chin lift or nasal airway, to those requiring no modification. No patients in the study required endotracheal intubation. Body mass index (BMI), male sex and ASA class 3 or above were associated with a need for AM. Patients in this study received anesthesia from a certified registered nurse anesthetist (CRNA) and generally had a level of deep sedation and, thus, their care continues to meet the definition of MAC.

Rex et al. reviewed case series of endoscopist-directed propofol sedation published in MEDLINE, CINAHL and EMBASE over the period of 1966 to 2008, resulting in 646,080 procedures in 28 studies published between 2002 and 2008.¹⁷ Incidence of mask ventilations, endotracheal intubation, neurologic injuries and death were collected from the published studies and calculated to reveal a death rate 0.62 per 100,000 cases. A direct comparison group was not included in this review. The authors note that this death rate compares favorably to published surveys of death rates of endoscopic procedures utilizing opioids and benzodiazepines of 11 per 100,000. They also compare this to published data on the general anesthesia overall death rate of 1 – 2 per 100,000. As mentioned, a direct comparison group is not available, nor are death rates for endoscopic procedures under MAC. However, the incidence of published adverse events appears to be low.

Agostoni and colleagues evaluated a prospective database of 17,999 GI endoscopies performed under MAC during the period of October 2001 to December 2009.¹⁸ The authors identified 6 variables predicting any sedation-related complication using multivariate logistic regression models: age (1-year OR: 1.02 [95 percent confidence interval [CI]: 0.01 – 1.02]), BMI (1-point OR: 1.03 [95 percent CI: 0.02 – 1.05]), ASA score ("3 – 4" vs. "1 – 2" OR: 1.69 [95 percent CI: 1.44 – 1.99]), Mallampati score ("3 – 4" vs. "1 – 2" OR: 1.33 [95 percent CI: 1.04 – 1.70]), emergency nature of the procedure (OR: 1.48 [95 percent CI: 1.13 – 1.94]), length of the procedure (OR: 2.00 [95 percent CI: 1.78 – 2.24]). The authors noted the Mallampati score is used to assess potential difficulty in tracheal intubation and it is unclear why this score was predictive of any complication.

In a prospective cohort study of 470 ERCP patients receiving MAC, Berzin and colleagues reported adverse respiratory events were strongly associated with higher body mass index using multivariate regression models. (OR: 1.08; p = 0.0006).¹⁹ Patients with obesity experienced respiratory events almost twice as often as non-obese patients (p = 0.03). Higher ASA class was not associated with adverse respiratory events under MAC (OR: 1.2; p = 0.25) but was associated with cardiovascular events (OR: 2.88; p < 0.0001).

Conclusions
The evidence base comparing different anesthetic methods is not robust, consisting primarily of non-randomized comparisons and observational studies. A single RCT comparing propofol administration by anesthesiologists to that by non-anesthesiologists for sedation during colonoscopy did not show any differences in procedure time or patient satisfaction, and reported a higher rate of hypoxia in patients treated with propofol. However, a Cochrane review of randomized studies concluded that recovery time, discharge time and patient satisfaction were all improved with propofol compared to alternative agents. This review did not find any evidence of increased complications. However, this evidence base does not rule out an increased complication rate with propofol, since there is a low complication rate in general, thus making it difficult to discern differences in the absence of large RCTs.

Bronchoscopy
In 2009, Silvestri and colleagues published an RCT comparing 2 doses of the sedative agent fospropofol in patients undergoing diagnostic bronchoscopy.²⁰ The study was performed by pulmonologists without anesthesia supervision. Patients (n = 252) were randomly assigned to receive either 2 mg/kg or 6.5 mg/kg induction doses of fospropofol, followed by additional doses per protocol. All patients received a pre-procedural dose of fentanyl. The primary endpoint was sedation success using the Modified Observer’s Assessment of Alertness/Sedation (MOAA/S). A secondary endpoint was treatment success, as measured by percentage of patients who did not require alternate sedation or ventilation. The higher dose group had greater sedation success (88.7 percent vs. 27.5 percent, respectively; p < 0.001). Treatment success also favored the higher dose group (91.3 percent vs. 41.25, respectively; p < 0.001). Adverse events were higher for the higher dose group; for example, the number of patients requiring any type of airway assistance (33 vs. 14, or 21.5 percent vs. 13.6 percent, respectively). The trial does not compare alternate sedation approaches; that comparison is necessary to evaluate the clinical value of the fospropofol sedation strategy for bronchoscopic procedures.

The British Thoracic Society published guidelines for flexible bronchoscopy in 2001.²¹ With respect to sedation, the guidelines state that sedation should be offered, patients should be monitored during and immediately after the procedure and that at least two assistants, at least one a qualified nurse, should be in attendance. Resuscitation equipment should be readily available. The sedation agents are not specified. An update to these guidelines is expected in early 2013.²²

Interventional Pain Management Procedures
In 2008, Bernards and colleagues published a review of the literature around neurologic complications of regional anesthesia in anesthetized or heavily sedated patients.²³ Some experts postulate that the inability of a sedated patient to express atypical symptoms during a regional block may lead to increased risk of injury. No comparative studies have been done and limited information is available from registries. The American Society of Regional Anesthesia (ASRA) and Pain Medicine has acknowledged the scarce and conflicting literature on the topic and recommends carefully weighing the risks and benefits in considering performing those procedures while the patient is heavily sedated or anesthetized.²⁴

In 2005, ASA released a statement on anesthetic care during interventional pain procedures.²⁵ While recognizing that conditions exist that may make skilled anesthesia care necessary, most minor pain procedures, under most routine circumstances, do not require anesthesia care other than local anesthesia.

Other Procedures
Any procedure that may be complicated by patient characteristics noted in the policy statement may be appropriate for MAC.

Pregnancy
Concerns regarding procedures and sedation during pregnancy are two-fold: sensitivity of the fetus to the agents and/or procedural hypotension and maternal factors that increase sensitivity to sedation and that make intubation more difficult in an emergency situation. In a large (n = 720,000) Swedish registry of pregnant patients from the 1970s and 1980s, 5,405 operations took place.²⁶ Congenital malformations and stillbirths were not increased in the offspring of women having an operation. Incidence of low birth weight infants was increased as a result of both prematurity and intrauterine growth retardation. Neonatal death was also increased in the patients who had an operation. No specific types of anesthesia or operation were associated with these outcomes. The contribution of the underlying condition that led to the need for surgery could not be separated from the effects of the surgery or sedation/anesthesia.

Fetal heart rate monitoring is considered to be a more sensitive indicator of placental perfusion and fetal oxygenation than observations of maternal hemodynamic stability alone. The American College of Obstetricians and Gynecologists (ACOG) has recommended that the use of intermittent or continuous fetal monitoring during surgery be individualized.²⁷

Physiologic changes in pregnancy may require changes in standard doses of anesthetic or sedative agents. However, propofol does not generally require a change in loading dose for induction.²⁸ Physiologic changes in pregnancy may warrant MAC when airway protection becomes necessary, due to additional difficulties noted with emergent intubation in pregnant patients and the urgency to restore full oxygenation to the maternal and fetal patients.²⁹ Thus, MAC can be considered medically necessary for procedures performed during pregnancy.

Summary
Monitored anesthesia care is the use of anesthesia personnel during a procedure to provide various levels of sedation and analgesia (anesthesia), depending on the patient’s condition and the procedure being performed. This policy addresses the potential role of dedicated anesthesia providers during diagnostic or therapeutic procedures involving gastrointestinal endoscopy, bronchoscopy and interventional pain procedures performed in the outpatient setting.

Comparative evidence that supports the use of monitored anesthesia care in specific procedures is limited. Patient characteristics, such as comorbidities, airway features or the ability to cooperate with the proceduralist, are more indicative of the need for this service. Physician-directed moderate sedation is a safe and effective alternative to monitored anesthesia care for the majority of patients undergoing procedures in whom deep sedation or anesthesia is unnecessary, such as gastrointestinal endoscopy, bronchoscopy and interventional pain procedures. Propofol may be used both for general anesthesia and moderate sedation. The principal differences between propofol and the traditional agents used in these clinical trials of moderate sedation are a shorter recovery period (a mean of 14.2 minutes), shorter discharge time and higher overall satisfaction scores. Pain control and incidence of complication rates appear to be similar overall, but the available evidence does not rule out small differences in these outcomes. The use of monitored anesthesia care may be considered medically necessary in cases with specific risk factors or significant medical conditions as indicated in the policy statement.

Practice Guidelines and Position Statements
In 2004, and amended in 2009, the American Society of Anesthesiologists released a statement on the safe use of propofol:

"The Society believes that the involvement of an anesthesiologist in the care of every patient undergoing anesthesia is optimal. However, when this is not possible, non-anesthesia personnel who administer propofol should be qualified to rescue patients whose level of sedation becomes deeper than initially intended and who enter, if briefly, a state of general anesthesia."³⁰

Recent guidelines regarding sedation during endoscopy were released by the American Society for Gastrointestinal Endoscopy (ASGE).³¹ These guidelines indicate: "Adequate and safe sedation can be achieved in most patients undergoing routine esophagogastroduodenoscopy [EGD] and colonoscopy by using an intravenous benzodiazepine and opioid combination." These guidelines also include a discussion of use of propofol for routine endoscopy, and their overall conclusion is that "clinically important benefits in average-risk patients undergoing upper endoscopy and colonoscopy have not been consistently demonstrated with regard to patient satisfaction and safety. Therefore, the routine use of propofol in average-risk patients cannot be endorsed." In addition to addressing the efficacy and safety of propofol, the guidelines discuss the issue of who is qualified to administer propofol. The ASGE endorses gastroenterologist-directed propofol use when adequate training for its use has been achieved. Numerous case series studies were cited showing very low rates of clinical adverse events when propofol was administered by registered nurses under gastroenterologist supervision.

"A second type of pacemaker surgery that is sometimes performed involves the use of the thoracic method of implantation, which requires open surgery. Where the thoracic method is employed, general anesthesia is always used and should not require special medical documentation."

Appendix 1:
American Society of Anesthesiologists (ASA) physical status classification system for assessing a patient before surgery:

P1 — A normal, healthy patient

P2 — A patient with mild systemic disease

P3 — A patient with severe systemic disease

P4 — A patient with severe systemic disease that is a constant threat to life

P5 — A moribund patient who is not expected to survive without the operation

P6 — A declared brain-dead patient whose organs are being harvested]

Use of monitored anesthesia care is considered not medically necessary for gastrointestinal endoscopic, bronchoscopic or interventional pain procedures in patients at average risk related to use of anesthesia and sedation.

Appendix 2:
The Mallampati score is considered a predictor of difficult tracheal intubation and is routinely used in preoperative anesthesia evaluation.⁷ The score is obtained by having the patient extend the neck, open the mouth and extend the tongue while in a seated position. Patients are scored from Class 1 – 4 as follows:

Class I — The tonsils, uvula and soft palate are fully visible.

Class 2 — The hard and soft palate, uvula and upper portion of the tonsils are visible.

Class 3 — The hard and soft palate and the uvula base are visible.

Class 4 — Only the hard palate is visible.

Patients with Class 3 or 4 Mallampati scores are considered to be at higher risk of intubation difficulty. While the Mallampati score does not determine a need for monitored anesthesia care, it may be considered in determining risk for airway obstruction. Other tests to predict difficult tracheal intubation include the upper lip bite test, the intubation difficulty scale and the Cormack-Lehane grading system.

For reference, the add-on code for anesthesia for patient of extreme age is:

99100 — Anesthesia for patient of extreme age, younger than 1 year and older than 70 (List separately in addition to code for primary anesthesia procedure). 

References

1. American Society of Anesthesiologists (ASA). ASA position on monitored anesthesia care. Amended September 2, 2008. 
2. American Society of Anesthesiologists (ASA). Levels of sedation/analgesia. Amended October 29, 2009. 
3. American Society of Anesthesiologists (ASA). Distinguishing monitored Anesthesia care ("MAC") from moderate sedation/analgesia. Amended October 21, 2009. 
4. American Society of Anesthesiologists (ASA). Statement on qualifications of anesthesia provided in the office-based setting. Amended October 21, 2009. 
5. Liu H, Waxman DA, Main R et al. Utilization of anesthesia services during outpatient endoscopies and colonoscopies and associated spending in 2003-2009. JAMA 2012; 307(11):1178-84.
6. Fleisher LA. Assessing the value of "discretionary" clinical care: the case of anesthesia services for endoscopy. JAMA 2012; 307(11):1200-1.
7. Mallampati SR, Gatt SP, Gugino LD et al. A clinical sign to predict difficult tracheal intubation: a prospective study. Can Anaesth Soc J 1985; 32(4):429-34.
8. American Society of Anesthesiologists. Statement on nonoperating room anesthetizing locations. Amended October 2008. 
9. American Society of Anesthesiologists. Guidelines for ambulatory anesthesia and surgery. Amended October 2008. 
10. Fleisher LA, Pasternak LR, Herbert R et al. Inpatient hospital admission and death after outpatient surgery in elderly patients: importance of patient and system characteristics and location of care. Arch Surg 2004; 139(1):67-72.
11. Cohen LB, Delegge MH, Aisenberg J et al. AGA Institute review of endoscopic sedation. Gastroenterology 2007; 133(2):675-701.
12. Singh H PW, Cheang M, Choptain N, Inegbu E, Baron K, Taback SP. Propofol for sedation during colonoscopy. Cochrane Database Syst Rev 2008; (4):CD006268.
13. McQuaid KR, Laine L. A systematic review and meta-analysis of randomized, controlled trials of moderate sedation for routine endoscopic procedures. Gastrointest Endosc 2008; 67(6):910-23.
14. Poincloux L, Laquiere A, Bazin JE et al. A randomized controlled trial of endoscopist vs. anaesthetist-administered sedation for colonoscopy. Dig Liv Dis 2011; 43(7):553-8.
15. Horiuchi A, Nakayama Y, Hidaka N et al. Low-dose propofol sedation for diagnostic esophagogastroduodenoscopy: results in 10,662 adults. Am J Gastroenterol 2009; 104(7):1650-5.
16. Cote GA, Hovis RM, Ansstas MA et al. Incidence of sedation-related complications with propofol use during advanced endoscopic procedures. Clin Gastroenterol Hepatol 2010; 8(2):137-42.
17. Rex DK, Deenadayalu VP, Eid E et al. Endoscopist-directed administration of propofol: a worldwide safety experience. Gastroenterology 2009; 137(4):1229-37; quiz 518-9.
18. Agostoni M, Fanti L, Gemma M et al. Adverse events during monitored anesthesia care for GI endoscopy: an 8-year experience. Gastrointest Endosc 2011; 74(2):266-75.
19. Berzin TM, Sanaka S, Barnett SR et al. A prospective assessment of sedation-related adverse events and patient and endoscopist satisfaction in ERCP with anesthesiologist-administered sedation. Gastrointest Endosc 2011; 73(4):710-7.
20. Silvestri GA, Vincent BD, Wahidi MM et al. A phase 3, randomized, double-blind study to assess the efficacy and safety of fospropofol disodium injection for moderate sedation in patients undergoing flexible bronchoscopy. Chest 2009; 135(1):41-7.
21. British Thoracic Society guidelines on diagnostic flexible bronchoscopy. Thorax 2001; 56 Suppl 1:i1-21.
22. British Thoracic Society Guidelines. 
23. Bernards CM, Hadzic A, Suresh S et al. Regional anesthesia in anesthetized or heavily sedated patients. Reg Anesth Pain Med 2008; 33(5):449-60.
24. Neal JM, Bernards CM, Hadzic A et al. ASRA Practice Advisory on Neurologic Complications in Regional Anesthesia and Pain Medicine. Reg Anesth Pain Med 2008; 33(5):404-15.
25. American Society of Anesthesiologists (ASA). Statement on anesthetic care during interventional pain procedures for adults. Amended October 20, 2010. 
26. Mazze RI, Kallen B. Reproductive outcome after anesthesia and operation during pregnancy: a registry study of 5405 cases. Am J Obstet Gynecol 1989; 161(5):1178-85.
27. ACOG Committee Opinion Number 284, August 2003: Nonobstetric surgery in pregnancy. Obstet Gynecol 2003; 102(2):431.
28. Higuchi H, Adachi Y, Arimura S et al. Early pregnancy does not reduce the C(50) of propofol for loss of consciousness. Anesth Analg 2001; 93(6):1565-9.
29. McDonnell NJ PM, Clavisi OM et al.; ANZCA Trials Group. Difficult and failed intubation in obstetric anaesthesia: an observational study of airway management and complications associated with general anaesthesia for caesarean section. Int J Obstet Anesth 2008; 17(4):292-7.
30. American Society of Anesthesthiologists (ASA). Statement of the safe use of propofol. Amended October 2009. 
31. Lichtenstein DR, Jagannath S, Baron TH et al. Sedation and anesthesia in GI endoscopy. Gastrointest Endosc 2008; 68(5):815-26.

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross Blue Shield Association technology assessment program (TEC) and other nonaffiliated technology evaluation centers, reference to federal regulations, other plan medical policies and accredited national guidelines.

"Current Procedural Terminology © American Medical Association. All Rights Reserved" 

History From 2014 Forward   

05/03/2023	Annual review, no change to policy intent.
05/02/2022	Annual review, no change to policy intent.
05/05/2021	Annual review, no change to policy intent.
05/01/2020	Annual review, no change to policy intent.
05/01/2019	Annual review, no change to policy intent.
05/02/2018	Annual review, no change to policy intent.
09/28/2017	Interim review, updating conscious sedation policy language to remove age criteria for coding. No other changes made.
05/16/2017	Annual review, no change to policy intent.
05/03/2016	Annual review, no change to policy intent.
01/26/2016	Interim review to correct typo in modifier section of policy.
05/05/2015	Annual review, no change to policy.
05/06/2014	Annual review. No change in policy.