MAC vs. General: Why Misclassifying Your Cases Can Cost Your Practice

-->December 21, 2016Magazine

    By: Hal Nelson, CPC, Vice President of Compliance

    Most practices are aware that any case where a patient loses consciousness and/or the ability to respond purposefully should be designated as a “general” anesthetic, per ASA guidelines. However, some providers erroneously classify these cases as “MAC” anesthetics, particularly those involving Propofol, when submitting to anesthesia billing services. Not only does this misclassification result in increased payer scrutiny for medical necessity, it also prohibits you from being able to bill separately for post-op pain blocks. According to ASA guidelines and the ASA’s statement on “Reporting Postoperative Pain Procedures in Conjunction with Anesthesia”:

    “Placement of epidurals and peripheral nerve blocks for postoperative pain control is separate and distinct from surgical anesthesia services. Valuations for anesthetic codes do not include the work of providing these additional services and payment for them should not be bundled with that of the anesthetic service. These procedures may be reported in conjunction with an anesthesia service when certain specific conditions are met. A key consideration is clear recognition of the difference between regional anesthesia that is performed as the primary surgical anesthetic as opposed to that which is intended primarily to provide postoperative analgesia. Epidurals and peripheral nerve blocks performed for postoperative pain control may be separately reported whether they are administered preoperatively, intra-operatively or postoperatively. A provider may bill for a postoperative pain procedure as a service separate from the anesthetic if the pain procedure is employed primarily for postoperative analgesia and if the following conditions apply:

    1. The anesthesia for the surgical procedure was not dependent upon the efficacy of the regional anesthetic technique –

    For example, if a femoral nerve block is placed prior to knee surgery to provide prolonged postoperative analgesia, then a general, spinal or epidural anesthetic would have to be used for the actual knee surgery rather than simply monitored anesthesia care (MAC), the regional block alone or I.V. sedation to properly report the regional block separately. In this setting, if the patient was provided a block and only sedation was added, then it would be clear that the femoral block was the primary anesthetic rather than a mode of postoperative analgesia.”

    To ensure that your group is capturing all of the revenue that you are entitled to, it is a good practice to have your providers review any case where “MAC” anesthesia is listed along with a post-op pain charge and to ask the question “Did the patient lose consciousness at any time during this case?” If the answer is yes, then you will want to be sure to change the mode of anesthesia to “general” before submitting the case to Medac’s anesthesia billing services.