![]() | Clinical UM Guideline |
Subject: Anesthesia Services for Interventional Pain Management Procedures | |
Guideline #: CG-MED-78 | Publish Date: 09/27/2023 |
Status: Reviewed | Last Review Date: 08/10/2023 |
Description |
This document addresses the medical necessity of anesthesia services, including monitored anesthesia care (MAC), for interventional pain management procedures. Interventional pain management procedures include, but are not limited to, diagnostic or therapeutic nerve blocks, diagnostic or therapeutic injections, and percutaneous image guided procedures. This document does not address whether or not reimbursement is provided for the anesthesia service and it is not intended to guide the billing and reimbursement of anesthesia services.
Note: This document does not address moderate sedation. For more information on moderate sedation, please see the following:
Clinical Indications |
Medically Necessary:
For interventional pain management procedures, including but not limited to nerve blocks, anesthesia services including monitored anesthesia care (MAC) are considered medically necessary when the following criteria have been met:
Note: Complex procedures and procedures in high-risk individuals may justify the use of an anesthesiologist or anesthetist to provide conscious sedation or deep sedation. See Appendix for physical status classifications. The presence of a stable, treated condition of itself is not necessarily sufficient.
Not Medically Necessary:
Anesthesia services for interventional pain management procedures are considered not medically necessary for all other indications.
Coding |
The following codes for treatments and procedures applicable to this guideline are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.
When services may be Medically Necessary when criteria are met:
For the following anesthesia procedures related to pain management services
CPT |
|
01937 | Anesthesia for percutaneous image-guided injection, drainage or aspiration procedures on the spine or spinal cord; cervical or thoracic |
01938 | Anesthesia for percutaneous image-guided injection, drainage or aspiration procedures on the spine or spinal cord; lumbar or sacral |
01939 | Anesthesia for percutaneous image-guided destruction procedures by neurolytic agent on the spine or spinal cord; cervical or thoracic |
01940 | Anesthesia for percutaneous image-guided destruction procedures by neurolytic agent on the spine or spinal cord; lumbar or sacral |
01941 | Anesthesia for percutaneous image-guided neuromodulation or intravertebral procedures (eg, kyphoplasty, vertebroplasty) on the spine or spinal cord; cervical or thoracic |
01942 | Anesthesia for percutaneous image-guided neuromodulation or intravertebral procedures (eg, kyphoplasty, vertebroplasty) on the spine or spinal cord; lumbar or sacral |
01991 | Anesthesia for diagnostic or therapeutic nerve blocks and injections (when block or injection is performed by a different physician or other qualified health care professional); other than the prone position |
01992 | Anesthesia for diagnostic or therapeutic nerve blocks and injections (when block or injection is performed by a different physician or other qualified health care professional); prone position |
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ICD-10 Diagnosis |
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| All diagnoses |
When services are Not Medically Necessary:
For the procedure codes listed above when criteria are not met.
Note: The following list of anesthesia service modifiers is for informational purposes:
| CPT Physical Status Modifiers |
P1 | A normal healthy patient (Class I) |
P2 | A patient with mild systemic disease (Class II) |
P3 | A patient with severe systemic disease (Class III) |
P4 | A patient with severe systemic disease that is a constant threat to life (Class IV) |
| HCPCS Anesthesia Modifiers |
G8 | Monitored anesthesia care (MAC) for deep complex, complicated, or markedly invasive surgical procedure |
G9 | Monitored anesthesia care for patient who has history of severe cardio-pulmonary condition |
QS | Monitored anesthesia care service |
Discussion/General Information |
Interventional pain management procedures are typically performed to diagnose or treat chronic pain conditions. These procedures are often performed without the use of sedation or with moderate sedation administered or overseen by the practitioner performing the procedure. However, when the procedure is complex or when the individual has significant medical conditions, a second practitioner may be needed to provide MAC. MAC is an anesthetic service for a diagnostic or therapeutic procedure in which a qualified anesthesia practitioner (for example, an anesthesiologist or nurse anesthetist) provides sedation, monitors vital functions, and treats complications.
In the Position on Monitored Anesthesia Care (ASA, 2018), the American Society of Anesthesiologists (ASA) defines MAC as the following:
Monitored anesthesia care is a specific anesthesia service performed by a qualified anesthesia provider, for a diagnostic or therapeutic procedure. Indications for monitored anesthesia care include, but are not limited to, the nature of the procedure, the patient’s clinical condition and/or the need for deeper levels of analgesia and sedation than can be provided by moderate sedation (including potential conversion to a general or regional anesthetic). Unlike monitored anesthesia care, moderate sedation is a proceduralist directed service which does not include a qualified anesthesia provider’s periprocedural assessment and has the inherent limitations that are policy directed for the non-anesthesia qualified provider. Moderate sedation is a proceduralist directed service that may be governed by separate institutional policies.
Monitored anesthesia care includes all aspects of anesthesia care – a preprocedure assessment and optimization, intraprocedure care and postprocedure management that is inherently provided by a qualified anesthesia provider as part of the bundled specific service. During monitored anesthesia care, the anesthesiologist provides or medically directs a number of specific services, including but not limited to:
Monitored anesthesia care may include varying levels of sedation, awareness, analgesia and anxiolysis as necessary. The qualified anesthesiologist provider of monitored anesthesia care must be prepared to convert to general anesthesia and respond to the pathophysiology (airway and hemodynamic changes) of procedure and position in the management in induction of general anesthesia when necessary.
The ASA, in a Statement on Anesthetic Care During Interventional Pain Procedures for Adults (ASA, 2021), states the following:
Use of sedation and/or anesthesia during the performance of pain procedures requires balancing the needs of the patient with the potential risks. The Committee recognizes the provision of procedural sedation or anesthesia as a separate and distinct service from the pain procedure, thus requiring specific training and credentialing as detailed in the ASA “Statement on Granting Privileges for Administration of Moderate Sedation to Practitioners Who Are Not Anesthesia Professionals.” When sedation is provided during the performance of a pain procedure, it should allow the patient to be responsive during critical portions of the procedure, e.g., to report potential procedure-related paresthesia, acute changes in pain intensity or function, or potential toxicities.
Interventional pain procedures generally only require local anesthesia; however, patients may elect to also receive supplemental sedation. For most patients who require supplemental sedation, the physician performing the interventional pain procedure(s) can prescribe minimal sedation/analgesia (anxiolysis) or moderate (conscious) sedation as part of the procedure. For a limited number of patients, an anesthesia care team may be required (see ASA “Statement on the Anesthesia Care Team”). Examples of procedures that typically do not require moderate sedation or an anesthesia care team include but are not limited to epidural steroid injections; epidural blood patch; trigger point injections; shoulder, hip, sacroiliac, facet and knee joint injections; medial branch nerve blocks; and peripheral nerve blocks.
Significant patient anxiety and/or medical comorbidities may be an indication for moderate (conscious) sedation or anesthesia care team services. In addition, procedures that require the patient to remain motionless for a prolonged period of time and/or remain in a painful position may require moderate sedation or anesthesia care team services. Examples of such procedures include but are not limited to sympathetic blocks (celiac plexus, paravertebral, and hypogastric); chemical or radiofrequency ablation; percutaneous discectomy; vertebral augmentation procedures; trial spinal cord stimulator lead placement; permanent spinal cord stimulator generator and lead implantation; and intrathecal pump implantation.
Anesthesia services are not the same as moderate (conscious) sedation. For more information, see the ASA Statements “Distinguishing Monitored Anesthesia Care (‘MAC’) from Moderate Sedation/Analgesia (Conscious Sedation)” and “Continuum of Depth of Sedation; Definition of General Anesthesia and Levels of Sedation/Analgesia.”
References |
Government Agency, Medical Society, and Other Authoritative Publications:
Websites for Additional Information |
Index |
Anesthesia Services
Interventional Pain Management
Monitored Anesthesia Care (MAC)
History |
Status | Date | Action |
Reviewed | 08/10/2023 | Medical Policy & Technology Assessment Committee (MPTAC) review. Revised References and Websites sections. Updated Coding section with informational note regarding CPT and HCPCS modifiers. |
Reviewed | 08/11/2022 | MPTAC review. Updated References and Websites sections. |
| 12/29/2021 | Updated Coding section with 01/01/2022 CPT changes; added 01937-01942 effective 01/01/2022 replacing 01935, 01936 deleted 12/31/2021. |
Reviewed | 08/12/2021 | MPTAC review. References, Websites for Additional Information, and Appendix sections updated. |
Reviewed | 08/13/2020 | MPTAC review. References, Websites, and Appendix sections updated. Reformatted Coding section. |
Reviewed | 08/22/2019 | MPTAC review. Discussion/General Information, References and Websites sections updated. |
New | 11/08/2018 | MPTAC review. Initial document development. |
Appendix |
American Society of Anesthesiology Physical Status Classifications:
ASA I A normal healthy patient
ASA II A patient with mild systemic disease
ASA III A patient with severe systemic disease
ASA IV A patient with severe systemic disease that is a constant threat to life
ASA V A moribund patient who is not expected to survive without the operation
ASA VI A declared brain-dead patient whose organs are being removed for donor purposes
(ASA Physical Status Classification System, 2020)
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