New Novitas LCD for Monitored Anesthesia Care (MAC) and Propofol

12/28/2012 – A new monitored anesthesia care (MAC) local coverage determination (LCD) policy (L27489) from Medicare contractor Novitas Solutions, Inc., (covering Pennsylvania, New Jersey, Maryland, District of Columbia and Delaware) took effect on November 15, 2012. The gist of the LCD is that monitored anesthesia care (MAC) and the administration of propofolmust be provided by qualified anesthesia personnel and that these personnel must be continuously present to monitor the patient and provide anesthesia care.  The LCD says that Propofol can be a dangerous drug, and patients should be continuously monitored for early signs of hypotension, apnea, airway obstruction, and/or oxygen desaturation.

The local guideline follows the CMS (Centers for Medicare and Medicaid) memo entitled “Revised Hospital Anesthesia Services Interpretive Guidelines’, issued on February 5, 2010, which stated that “Anesthesia services, which include both anesthesia and analgesia, are provided along a continuum, ranging from the application of local anesthetics for minor procedures to general anesthesia for patients who require loss of consciousness as well as control of vital body functions in order to tolerate invasive operative procedures.  This continuum also includes minimal sedation, moderate sedation/analgesia (conscious sedation), monitored anesthesia care (MAC), and regional anesthesia.”

The guidelines also stated that Propofol, a fast-acting, non-analgesic sedative used for deep sedation could only be administered by professionals in Medicare settings with the credentials to provide deep sedation or general anesthesia.[1]CMS changed Propofol’s package insert to say the drug is only indicated for general anesthesia, monitored anesthesia care (MAC), and for sedation of the mechanically ventilated patient.

The 2010 guidelines triggered much debate over who is authorized to administer Propofol.  The American Society of Anesthesiologists (ASA) and American Association of Nurse Anesthetists (AANA) issued a joint statement that Propofol should be administered only by persons trained in the administration of general anesthesia who are not also involved with the procedure, based on their belief that sedation is a continuum, and you can’t predict how a patient will respond. Also that Propofol can cause rapid and profound changes, and there is not reversal for Propofol.

In contrast, the American College of Gastroenterology, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy, and Society of Gastroenterology Nurses and Associates endorse nurse-administered propofol under the direction of a physician if state regulations allow it, if the nurse is trained in the use of drugs causing deep sedation, and if the nurse is capable of rescuing patients from general anesthesia or severe respiratory depression.[2]

While properly trained physicians can administer propofol, regulations governing its administration by non-physician personnel vary on a state-by-state basis. Some states have said that administration of propofol for sedation is not within the scope of practice for RNs (e.g., Florida) and some say that it is within the scope of the RN to administer drugs such as propofol for sedation, but no anesthetic agents for anesthesia (e.g., Maine).[3]

However, for Medicare patients, this recent LCD emphasizes that the CMS requirements of administering propofol and billing monitored anesthesia care 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 requirements for general anesthesia are met. 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 necessity for the MAC service must be clearly reflected in the medical record.  Compliance with the provisions in this LCD may be monitored and addressed through post payment data analysis and subsequent medical review audits.

From the new MAC policy: “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 (procedures where “moderate” anesthesia is usually required) 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 code V58.83 (Encounter for therapeutic drug monitoring) should be used when patient provided monitored anesthesia care monitoring is secondary, or integral, to the use of propofol and that claims must include the verbiage, “propofol” in the narrative field of the claim.”[4]

For MAC cases where propofol is used, there is no change at this point.  However, for cases where Propofol is not used, medical necessity needs to be met for the patient to qualify for MAC anesthesia.  For cases where medical necessity is not met on the billing or anesthesia document and a drug other than propofol is used, AHS will hold the document and return it to the provider to identify the medical necessity. In the event a qualifying medical necessity does not exist, the claim will go to Medicare with a GZ modifier which will result in a denial of payment.


[1] Chartier, Keith, “Propodol: Who (or What) Should be Allowed to Administer It?”,  June 30, 2011,

[2] Dix, Kathy, “Conscious Sedation,”

[3] Dix, Kathy, “Conscious Sedation,”

[4] LCD L27489,