SPECIAL ANNOUNCEMENT for Massachusetts Providers
Blue Cross/Blue Shield of Massachusetts (BCBSMA) has announced that, effective January 1, 2024, it is implementing a set of diagnosis-driven claim edits to reinforce its existing medical policy (MP 154) that sets forth the conditions for payment of monitored anesthesia care (MAC) in an endoscopy case in the outpatient setting. Essentially, the BCBSMA announcement is giving anesthesia providers a heads-up that where a patient’s diagnosis or physical status does not meet the MP 154 threshold for billing MAC, the provider will not receive reimbursement from the payer. Where a provider believes that payment may be an issue, he/she should have the patient sign the attached waiver form prior to the service.
Conditions that would meet the medical necessity threshold of MP 154 include, for example, the following:
- ASA status III – V
- Severe obesity
- History of adverse reaction to sedation
- History of inadequate response to sedation
- Findings consistent with sleep apnea
The use of MAC is considered NOT medically necessary for endoscopy procedures “in patients at low to average risk of complications related to the use of moderate sedation.” Furthermore, MAC for routine screening and diagnostic colonoscopy in ASA Class I patients is deemed to be NOT medically necessary.
Providers are encouraged to review MP 154 prior to the provision of MAC services to BCBSMA patients in endoscopy cases. The policy can be found here: 154 Monitored Anesthesia Care (MAC) (bluecrossma.org).