The Three Modes
When documenting anesthesia services, only three modes are recognized for anesthesia billing purposes. Accurate selection and documentation of the appropriate mode is essential, as it directly impacts reimbursement and compliance.
General Anesthesia (GA) is most commonly associated with surgical procedures that require the patient to be put to sleep. However, even in cases where this was not necessarily the intent, the provider would nevertheless need to indicate GA as the anesthesia mode on the medical record where certain conditions are met. According to the American Society of Anesthesiologists, a GA occurs where there is a “drug-induced loss of consciousness during which patients are not arousable.” Notice that there is no requirement that such conditions must extend during the entire portion of the case or that the patient be intubated in order for the technique to be labeled GA. If the patient loses consciousness at any point during the case where they are not arousable, the anesthesia technique should be documented as a GA on the anesthesia record. This unintended GA scenario may occur when propofol is administered in such amounts to cause the patient to lose consciousness at some point during the case.
Regional Anesthesia is reported when a spinal, epidural or nerve block is used as the primary anesthetic for the procedure. In these cases, the block itself constitutes the anesthetic service.
Monitored Anesthesia Care (MAC) is used for cases that do not meet the criteria for GA or regional anesthesia. Patients receiving MAC are not unconscious and are not required to have sedation. Payment for MAC is based on monitoring the patient in the event they may need to be placed under GA. While sedation is not required to bill MAC, most anesthesia providers will use some type of sedation during such a service. Again, if that sedation is propofol, the patient may end up losing consciousness. In that event, the provider will need to be prepared to mark GA on the anesthesia record, as noted above.
Why Mode Matters
Mode of anesthesia is unique to anesthesia billing and serves as a key indicator for when additional billing rules apply. For example, in orthopedic procedures, nerve blocks are frequently used. These blocks are not separately billable when they function as the primary anesthetic. A nerve block may only be separately reported when (a) GA is the anesthesia mode, AND (b) the block is performed solely for the purpose of post‑operative pain management.
In addition, cases where the provider lists MAC as the anesthesia technique will have that mode reflected on the claim form by having the QS modifier appended to the anesthesia code. Medicare uses this modifier to cross-check the case with their MAC policies to see if the case meets the policy criteria. Correctly identifying and documenting anesthesia mode ensures that these distinctions are clearly supported in the medical record.
The Mode in Endoscopy Cases
There continues to be discussion around the appropriate mode of anesthesia for endoscopic procedures. While certain agents, such as propofol, can lead to a patient losing consciousness, not all endoscopy centers are equipped to recover patients following GA. In these situations, the procedural staff may prefer to schedule endoscopy cases as MAC. So, what does that mean for the anesthesia group?
Where certain sites of service may have limitations on providing GA services, it will be up to the facility and the anesthesia group to discuss what those specific limitations are and whether the anesthesia team is able to perform its service within those limitations from both a patient care and compliance standpoint. At some point, the group and/or the facility may want to consult with their state-specific healthcare attorney to ensure that neither the facility nor the anesthesia group is at risk from a care, licensing or documentation perspective.
Reviewing Documentation Patterns
Reviewing documentation of anesthesia mode across a practice—especially when broken down by facility and case type—can yield significant insights for anesthesia providers. By analyzing this data, you may uncover important trends, spot inconsistencies, and reveal valuable opportunities for greater alignment and improvement in documentation practices.