General versus MAC: What’s More Appropriate for GI?

Author: Tony Mira

F1rst News

While there is virtually no difference in payment success for general versus MAC GI cases, some anesthesia providers continue to document MAC—even where the patient loses consciousness.  Today’s article addresses the difference between these two anesthesia types and their current applications and implications in gastrointestinal cases.

A number of years ago, the ASA modified its definition of general anesthesia. Historically, if a patient was unconscious or could not respond purposefully for the preponderance of the case, it was considered a general anesthetic (GA). This language was later revised so that the current standard is that if a patient loses consciousness or is unable to respond purposefully for any portion of the case, the anesthesia type is automatically deemed to be GA.

What’s in A Name?

There are many reasons given for continuing to document a propofol anesthetic to a patient for an endoscopic procedure as MAC. Some are based on specific local and hospital requirements and regulations; but many are based on historical practice and custom, rather than a serious consideration of current norms. During our training sessions, most providers agree in concept that these cases should be documented as GA, but the statistical reality is that for many this is not what is actually happening. Something happens when they go from the class room to the operating room.

The most compelling argument for continuing to document these cases as MAC is a facility-specific consideration. Is the facility prepared to recover patients from a general anesthetic? Since many free-standing endoscopy centers, especially in the mid-Atlantic region, do not meet this criterion, it makes sense to document these cases as MAC. In our experience, however, such facilities represent a significant minority of endoscopic venues.

Some providers argue that because the surgeon and the patient expect a MAC anesthetic, it would be inappropriate to document the care as a general.  Such logic, however, flies in the face of the intent and purpose of an anesthesia consent. It is the nature of anesthesia care that the anesthesia provider alone decides what the best anesthesia care is based on the patient’s concerns and the surgeon’s requirements.

Difference in Payment?

There appears to be some concern that patients will question their bill. Actually, the billing distinction between a GA and a MAC is very subtle and probably transparent to most patients. There is no indication of the mode of anesthesia on a patient statement. It is only those claims submitted to Medicare that are affected. When the provider marks the primary mode of anesthesia as MAC, the claim must include a QS modifier appended to the ASA code. The significance of the modifier is to flag the case as potentially not needing a separate anesthesia provider. Most claims to other plans do not include any indication of the mode of anesthesia.

As a practical matter, the mode of anesthesia has no impact on the rate of payment. Claims adjudication patterns vary considerably by Medicare intermediary. In some cases, the use of the QS modifier does increase the percentage of cases denied for medical necessity. It should be noted, however, that in the current environment payer concern has less to do with the mode of anesthesia than with the physical status of the patient. As a general rule, we are now seeing a higher percentage of denials for endoscopic cases from all payers, irrespective of anesthesia mode. A number of plans have modified their policies to exclude ASA I and II patients.

Does the mode of anesthesia reported really matter? If the only consideration is getting paid for the case, the answer is no. Virtually all claims for endoscopic care ultimately get paid even if they are initially denied. There is one thing to keep in mind, however. Some Medicare jurisdictions have a MAC policy (formerly referred to as “local coverage determination”).  These policies basically limit payment for certain services (e.g., integumentary, endoscopy) unless there are certain co-morbidities or other considerations, such as age, heart issues, psychological disorders, etc. associated with the patient.  In these cases, you will want to ensure that your documentation (received by the billing office) contains these additional patient diagnoses/factors.

What Really Matters

Standards of care matter in anesthesia. Part of what makes anesthesia so safe is the consistent adherence to established protocols. Implicit here is the notion that the documentation completed by the provider, i.e., the anesthesia record, reflects the actual care provided.  While the ASA has provided some clarification in recent years with regard to the distinction between various levels of sedation, its overarching policy remains very consistent. The absence of consciousness or the ability to respond purposefully define general anesthesia. While some practices play with semantics to provide a work-around, terms such as “MAC with loss of consciousness” really defeat the purpose, and coders consider them GA cases. Let’s just call it what it is and do it consistently.

There is concern that patients are getting a mixed message when a surgeon tells them the case will be done with a MAC anesthetic, when in fact the patient will be unconscious. One of the great insights of the early authors of the ASA Relative Value Guide is that anesthesia providers are paid to make critical clinical decisions. The anesthesia record is designed to reflect that decision-making. Suggesting that providers should document something else does a disservice to the provider and the specialty.

After all, what is the role of the anesthesia provider? It is to assess the unique needs of the patient, the surgeon and any other considerations that may apply in the determination of the anesthesia plan. When anesthesia providers defer to external influence and pressure, they diminish the value of their service and specialty.