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December 1998
Volume 62 |
Number 12
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| ASA Updates Its
Position on Monitored Anesthesia Care |
L. Charles Novak, M.D.,
Chair
Committee on Economics
At the ASA Annual Meeting in Orlando, Florida, the House of Delegates
adopted an extensive revision to ASA's "Position on Monitored
Anesthesia Care." The new statement, brought to the House through
the Committee on Economics, extensively revises and modernizes
the previous statement that had been in effect since 1986. The
House also removed from ASA publication the previous "ASA Policy
for the Reimbursement of Monitored Anesthesia Care," the principles
of which are incorporated in the revised position statement. The
text of the new position statement appears in Table 1.
Table 1
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ASA Position on Monitored Anesthesia
Care
(Approved by the ASA House of Delegates on October
21, 1998)
Monitored anesthesia care is a specific anesthesia
service in which an anesthesiologist has been requested
to participate in the care of a patient undergoing
a diagnostic or therapeutic procedure.
Monitored anesthesia care includes all aspects of
anesthesia care - a preprocedure visit, intraprocedure
care and postprocedure anesthesia management.
During monitored anesthesia care, the anesthesiologist
or a member of the anesthesia care team provides a
number of specific services, including but not limited
to:
- Monitoring of vital signs, maintenance of the
patient's airway and continual evaluation of vital
functions
- Diagnosis and treatment of 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 other medical services as needed
to accomplish the safe completion of the procedure
Monitored anesthesia care often includes the administration
of doses of medications for which the loss of normal
protective reflexes or loss of consciousness is likely.
Monitored anesthesia care refers to those clinical
situations in which the patient remains able to protect
the airway for the majority of the procedure. If,
for an extended period of time, the patient is rendered
unconscious and/or loses normal protective reflexes,
then anesthesia care shall be considered a general
anesthetic.
Because monitored anesthesia care is a physician
service provided to an individual patient and is based
on medical necessity, it should be subject to the
same level of reimbursement as general or regional
anesthesia. Accordingly, the ASA Relative Value Guide
provides for the use of proper basic procedural units,
time units and age and risk modifier units as the
basis for determining reimbursement.*
*It is the official policy of the American Society
of Anesthesiologists, Inc. that anesthesiologists
are free to choose whatever arrangement they prefer
for compensation of their professional services. The
Society does not consider the compensation arrangement
so chosen to be a matter of professional ethics.
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Review of the 1986 position statement by the Committee on Economics
revealed several elements that are outdated or no longer applicable.
The statement was directed too much toward a single third-party
payer (Medicare) and contained language that, at this point in
time, seems defensive or apologetic. The revisions remove references
to Medicare policy and define the service in positive terms.
Monitored anesthesia care (MAC), as now described, includes
the following specific and important elements:
- It is a clinical anesthesia service.
- Involvement of an anesthesiologist is requested by another
physician.
- Personnel performing the service possess training and skills
usually found only in qualified anesthesia personnel.
- Usual pre-, intra- and postprocedure anesthesia services
are required.
- Level of sedation, short of general anesthesia, may vary
widely during a single case and from case to case.
- Since MAC is a complete anesthesia service, billing and reimbursement
levels should be the same as other anesthesia services.
MAC Versus Conscious Sedation
MAC, because it specifically involves a second independently
functioning physician, is clearly distinguished from the clinical
service known as conscious sedation. Conscious sedation, as described
by codes 99141 and 99142 in Current Procedural Terminology, involves
an individual, directed by the physician performing the procedure,
administering medication and monitoring the patient with the intent
that the patient remain conscious and able to communicate during
the entire procedure.
Figure 1
Figure 1 graphically depicts the distinct difference
between conscious sedation and general anesthesia with regard
to level of consciousness and dose of drugs usually involved.
Monitored anesthesia care fills the gap and may overlap, to some
extent, both of the other services.
In recommending approval of the position statement to the House
of Delegates, the Reference Committee commented, "The intent of
MAC is to provide a requested physician anesthesia service of
observation, monitoring and care (without regard to level of sedation)
for a procedure and is based on medical necessity. We recognize
that there is a continuum of degrees of sedation even within one
anesthetic. Deep sedation (as defined in credentials for nonanesthesiologists)
should not be equated with MAC." The committee further commented
that definition of MAC in the statement "best represents current
practice."
Educating Others About Value of MAC
Monitored anesthesia care, a term we created, remains with us
and has evolved over the years. Improved pharmacological agents
and monitoring technology have allowed us to provide more flexibility
in the anesthesia care we provide to our patients.
We continue to be faced with the need to "educate" third-party
payers and others about the value to patients, to their safety
and to the efficiency of care provided by the availability of
MAC. The revised "Position on Monitored Anesthesia Care" should
help us in these efforts.
L. Charles Novak, M.D., is
a practicing anesthesiologist, Wenatchee Anesthesia Associates,
Wenatchee, Washington.
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