Developed By: Committee on Economics
Last Amended: October 17, 2018 (original approval: October 27, 2004)
Moderate Sedation/Analgesia (Conscious Sedation; hereinafter known as Moderate Sedation) is a physician service recognized in the CPT procedural coding system. During Moderate Sedation, a physician supervises or personally administers sedative and/or analgesic medications that can allay patient anxiety and limit pain during a diagnostic or therapeutic procedure. During Moderate Sedation the responsible physician typically assumes the dual role of performing the procedure and supervising the sedation. Such drug- induced depression of a patient’s level of consciousness to a “moderate” level of sedation, as defined in the Joint Commission (TJC) standards, is intended to facilitate the successful performance of the diagnostic or therapeutic procedure while providing patient comfort and cooperation. Physicians providing moderate sedation must be qualified to recognize “deep” sedation, manage its consequences and adjust the level of sedation to a “moderate” or lesser level. The continual appraisal of the effects of sedative or analgesic medications on the level of consciousness and on cardiac and respiratory function is an integral element of this service.
The American Society of Anesthesiologists has defined Monitored Anesthesia Care (see Position on Monitored Anesthesia Care, updated on October 17, 2018). This physician service can be distinguished from Moderate Sedation in several ways. An essential component of MAC is the periprocedural anesthesia assessment and understanding of the patient’s coexisting medical conditions and management of the patient’s actual or anticipated physiological derangements during a diagnostic or therapeutic procedure. While Monitored Anesthesia Care may include the administration of sedatives and/or analgesics often used for Moderate Sedation, the qualified anesthesia provider of MAC is focused exclusively and continuously on the patient for any attendant airway, hemodynamic and physiologic derangements. Further, the provider of MAC must be prepared and qualified to convert to general anesthesia. The proceduralist providing moderate sedation may have their attention diverted to their primary focus, the procedure. Additionally, a provider’s ability to intervene to rescue a patient’s airway from any sedation-induced compromise is a prerequisite to the qualifications to provide Monitored Anesthesia Care. By contrast, Moderate Sedation is not expected to induce depths of sedation that would impair the patient’s respiratory function or ability to maintain the integrity of his or her airway. These components of Monitored Anesthesia Care are unique aspects of an anesthesia service that are not part of Moderate Sedation.
The administration of sedatives, hypnotics, analgesics, as well as anesthetic drugs commonly used for the induction and maintenance of general anesthesia is often, but not always, a part of Monitored Anesthesia Care. In some patients who may require only minimal sedation, MAC is often indicated because even small doses of these medications could precipitate adverse physiologic responses that would necessitate acute clinical interventions and resuscitation. The attention of the proceduralist is focused on the completion of the procedure, not physiologic alterations. If a patient’s condition and/or a procedural requirement is likely to require sedation to a “deep” level or even to a transient period of general anesthesia, only a practitioner privileged to provide anesthesia services should be allowed to manage the sedation. Due to the strong likelihood that “deep” sedation may, with or without intention, transition to general anesthesia, the skills of an anesthesia provider are necessary to manage the effects of general anesthesia on the patient as well as to return the patient quickly to a state of “deep” or lesser sedation.
Like all anesthesia services, Monitored Anesthesia Care includes an array of post-procedure responsibilities beyond the expectations of practitioners providing Moderate Sedation, including assuring a return to baseline consciousness, relief of pain, management of adverse physiological responses or side effects from medications administered during the procedure, as well as the diagnosis and treatment of co-existing medical problems.
Monitored Anesthesia Care allows for the safe administration of a maximal depth of sedation in excess of that provided during Moderate Sedation. The ability to adjust the sedation level from full consciousness to general anesthesia during the course of a procedure provides maximal flexibility in matching sedation level to patient needs and procedural requirements. In situations where the procedure is more invasive or when the patient is especially fragile, optimizing sedation level is necessary to achieve ideal procedural conditions.
In summary, Monitored Anesthesia Care is a physician service that is clearly distinct from Moderate Sedation due to the expectations and qualifications of the provider who must be able to utilize all anesthesia resources to support life and to provide patient comfort and safety during a diagnostic or therapeutic procedure.