Monitored Anesthesia Care CPT Code list - 00100 - 00400- 01999 AND DX list


Notice: It is not appropriate to bill Medicare for services that are not covered (as described by this entire LCD) as if they are covered.
  • In keeping with the American Society of Anesthesiologists’ standards for monitoring, MAC should be provided by qualified anesthesia personnel in accordance with individual state licensure. These individuals must be continuously present to monitor the patient and provide anesthesia care.
  • During MAC, the patient’s oxygenation, ventilation, circulation and temperature should be evaluated by whatever methods are deemed most suitable by the attending anesthetist. It is anticipated that newer methods of non-invasive monitoring such as pulse oximetry and capnography will be frequently relied upon. Close monitoring is necessary to anticipate the need for general anesthesia administration or for the treatment of adverse physiologic reactions such as hypotension, excessive pain, difficulty breathing, arrhythmias, adverse drug reactions, etc. In addition, the possibility that the surgical procedure may become more extensive and/or result in unforeseen complications requires comprehensive monitoring and/or anesthetic intervention.
  • The following CMS requirements for this type of anesthesia should be the same as for general anesthesia with regard to:
    • The performance of preanesthetic examination and evaluation.
    • The prescription of the anesthesia care required.
    • The completion of an anesthesia record.
    • The administration of necessary medications and the provision of indicated postoperative anesthesia care.
  • Appropriate documentation must be available to reflect pre- and postanesthetic evaluations and intraoperative monitoring.
  • The MAC service rendered must be reasonable, appropriate and medically necessary.
  • Anesthesia procedures listed in the “CPT/HCPCS Codes” section of this LCD are examples of those that are usually provided by the attending surgeon and are included in the global fee and are not separately billable. In certain instances; however, MAC provided by anesthesia personnel may be necessary for these procedures if the patient has one or more of the conditions or situations found in the “ICD-9-CM Codes That Support Medical Necessity” section of this LCD. MAC may be necessary for these active and serious accompanying situations or conditions to ensure smooth anesthesia (and surgery) by the prevention of adverse physiologic complications. The use of anesthesia modifiers, when the CPT code is not fully descriptive, is required as follows:
    • G8 anesthesia modifier – used to indicate certain deep, complex, complicated or markedly invasive surgical procedures. This modifier is to be applied to the following anesthesia codes only: 00100, 00300, 00400, 00160, 00532 and 00920.
    • G9 anesthesia modifier – represents “a history of severe cardiopulmonary disease” and should be utilized whenever the proceduralist feels the need for MAC due to a history of advanced cardiopulmonary disease. The documentation of this clinical decision-making process and the need for additional monitoring must be clearly documented in the medical record.
    • Anesthesia codes utilized to indicate the clinical condition of the patient receiving MAC: P1 healthy individual with minimal anesthesia risk, P2 mild systemic disease, P3 severe systemic disease with intermittent threat of morbidity or mortality, P4 severe systemic illness with ongoing threat of morbidity or mortality, P5 premorbid condition with high risk of demise unless procedural intervention is performed.
Special conditions and/or criteria must be supported by documentation in the medical record.
  • Reimbursement for MAC will be the same amount allowed for full general anesthesia services if all requirements listed under these indications are met. The provision of quality MAC is mandatory and requires the same expertise and the same effort (work) as required in the delivery of a general anesthetic. If the requirements are not fulfilled or the procedures are unnecessary, payment will be denied in full.
  • For procedures that do not usually require anesthesia services, MAC could be covered when the patient’s condition requires the presence of qualified anesthesia personnel to perform monitored anesthesia in addition to the physician performing the procedure, and is so documented in the patient’s medical record.
  • The presence of an underlying condition alone, as reported by an ICD-9-CM diagnosis code, may not be sufficient evidence that MAC is necessary. The medical condition must be significant enough to impact on the need to provide MAC such as the patient being on medication or being symptomatic, etc. The presence of a stable, treated condition, of itself, is not necessarily sufficient.
  • Conditions listed under the “Diagnoses That Support Medical Necessity” section of this LCD, if matched with anesthesia procedures in the “CPT/HCPCS Codes” section of this LCD, could support the need for MAC. Other disease states can also be considered if medical justification is demonstrated.
Notice: This LCD imposes diagnosis limitations that support diagnosis to procedure code automated denials. However, services performed for any given diagnosis must meet all of the indications and limitations stated in this policy, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS national coverage determinations, and all Medicare payment rules.
As published in CMS IOM 100-08, Section 13.5.1, to be covered under Medicare, a service shall be reasonable and necessary. When appropriate, contractors shall describe the circumstances under which the proposed LCD for the service is considered reasonable and necessary under Section 1862(a)(1)(A). Contractors shall consider a service to be reasonable and necessary if the contractor determines that the service is:
  • Safe and effective.
  • Not experimental or investigational (exception: routine costs of qualifying clinical trial services with dates of service on or after September 19, 2000, which meet the requirements of the clinical trials NCD are considered reasonable and necessary).
  • Appropriate, including the duration and frequency that is considered appropriate for the service, in terms of whether it is:
    • Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient’s condition or to improve the function of a malformed body member.
    • Furnished in a setting appropriate to the patient’s medical needs and condition.
    • Ordered and furnished by qualified personnel.
    • One that meets, but does not exceed, the patient’s medical need.
    • At least as beneficial as an existing and available medically appropriate alternative.
Bill Type Codes
Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.
11X, 12X, 13X, 18X, 21X, 83X
Revenue Codes
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.
Note: TrailBlazer has identified the Bill Type and Revenue Codes applicable for use with the CPT/HCPCS codes included in this LCD. Providers are reminded that not all the CPT/HCPCS codes listed can be billed with all Bill Type and/or Revenue Codes listed. CPT/HCPCS codes are required to be billed with specific Bill Type and Revenue Codes. Providers are encouraged to refer to the CMS Internet-Only Manual (IOM) Pub. 100-04, Claims Processing Manual, for further guidance.
037X
CPT/HCPCS Codes
Note:
Providers are reminded to refer to the long descriptors of the CPT codes in their CPT book. The American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS) require the use of short CPT descriptors in policies published on the Web.
Procedures listed below usually do not require general, regional or MAC anesthesia.
00100©
Anesth, salivary gland
00124©
Anesth, ear exam
00148©
Anesth, eye exam
00160©
Anesth, nose/sinus surgery
00164©
Anesth, biopsy of nose
00300©
Anesth, head/neck/ptrunk
00322©
Anesth, biopsy of thyroid
00400©
Anesth, skin, ext/per/atrunk
00410©
Anesth, correct heart rhythm
00454©
Anesth, collar bone biopsy
00520©
Anesth, chest procedure
00522©
Anesth, chest lining biopsy
00524©
Anesth, chest drainage
00530©
Anesth, pacemaker insertion
00532©
Anesth, vascular access
00635©
Anesth, lumbar puncture
00640©
Anesth, spine manipulation
00702©
Anesth, for liver biopsy
00740©
Anesth, upper gi visualize
00810©
Anesth, low intestine scope
00842©
Anesth, amniocentesis
00920©
Anesth, genitalia surgery
00921©
Anesth, vasectomy
01130©
Anesth, body cast procedure
01380©
Anesth, knee joint procedure
01420©
Anesth, knee joint casting
01490©
Anesth, lower leg casting
01680©
Anesth, shoulder casting
01682©
Anesth, airplane cast
01730©
Anesth, uppr arm procedure
01780©
Anesth, upper arm vein surg
01782©
Anesth, uppr arm vein repair
01820©
Anesth, lower arm procedure
01829©
Anesth, dx wrist arthroscopy
01860©
Anesth, lower arm casting
01916©
Anesth, dx arteriography
01920©
Anesth, catheterize heart
01922©
Anesth, cat or mri scan
01930©
Anes, ther interven rad, vein
01935©
Anesth, perc img dx sp proc
01936©
Anesth, perc img tx sp proc
01991©
Anesth, nerve block/inj
01992©
Anesth, n block/inj, prone
01999©
Unlisted anesth procedure
Note: The QS modifier must be used with the anesthesia service provided if MAC is delivered.
ICD-9-CM Codes That Support Medical Necessity
The CPT/HCPCS codes included in this LCD will be subjected to “procedure to diagnosis” editing. The following lists include only those diagnoses for which the identified CPT/HCPCS procedures are covered. If a covered diagnosis is not on the claim, the edit will automatically deny the service as not medically necessary.
Medicare is establishing the following limited coverage for the CPT codes listed above:
Covered for:
038.0
Streptococcal septicemia
038.10–038.12
Staphylococcal septicemia
038.19
Other staphylococcal septicemia
038.2–038.3
Septicemia
038.40–038.44
Septicemia due to other gram-negative organism
038.49
Other septicemia due to gram-negative organisms
038.8–038.9
Other specified and unspecified septicemia
Note: Use of the diagnosis codes in the section above must be representative of the patient’s acute sepsis condition.
242.00–242.01
Toxic diffuse goiter
242.10–242.11
Toxic uninodular goiter
242.20–242.21
Toxic multinodular goiter
242.30–242.31
Toxic nodular goiter
242.40–242.41
Thyrotoxicosis from ectopic thyroid nodule
242.80–242.81
Thyrotoxicosis of other specified origin
242.90–242.91
Thyrotoxicosis without mention of goiter or other cause
243
Congenital hypothyroidism
244.0–244.3
Acquired hypothyroidism
244.8–244.9
Acquired hypothyroidism
250.00–250.03
Diabetes mellitus without mention of complication
250.10–250.13
Diabetes with ketoacidosis
250.20–250.23
Diabetes with hyperosmolarity
250.30–250.33
Diabetes with other coma
250.40–250.43
Diabetes with renal manifestations
250.50–250.53
Diabetes with ophthalmic manifestations
250.60–250.63
Diabetes with neurological manifestations
250.70–250.73
Diabetes with peripheral circulatory disorders
250.80–250.83
Diabetes with other specified manifestations
250.90–250.93
Diabetes with unspecified complication
251.0–251.5
Other disorders of pancreatic internal secretion
251.8–251.9
Other disorders of pancreatic internal secretion
252.00–252.02
Hyperparathyroidism
252.08
Other hyperparathyroidism
252.1
Hyperparathyroidism
252.8–252.9
Disorders of parathyroid gland
253.0–253.9
Disorders of the pituitary gland and its hypothalamic control
254.0–254.1
Diseases of thymus gland
254.8–254.9
Diseases of thymus gland
255.0
Cushing’s syndrome
255.10–255.14
Hyperaldosteronism
255.2–255.3
Disorders of adrenal glands
255.41–255.42
Corticoadrenal insufficiency
255.5–255.6
Disorders of adrenal glands
255.8–255.9
Disorders of adrenal glands
Note: Use of the diagnosis codes in the section above must be representative of the patient’s severe metabolic condition (e.g., a greatly elevated blood sugar, such as 300 mg. % ).
276.0–276.4
Disorders of fluid, electrolytes, and acid-base balance
276.50–276.52
Disorders of fluid, electrolytes, and acid-base balance
276.61
Transfusion associated circulatory overload
276.69
Other fluid overload
276.7–276.9
Disorders of fluid, electrolytes, and acid-base balance
Note: Use of the diagnosis code above must be representative of the patient’s electrolyte imbalance (e.g., sodium, potassium or calcium levels, etc., significantly outside normal limits).
277.00–277.02
Cystic fibrosis
Note: Use of the diagnosis codes in the section above would indicate that the patient has significant respiratory impairment related to this condition.
278.01
Morbid obesity
Note: Use of the diagnosis code above indicates the patient is at least two times ideal body weight.
278.03
Obesity hypoventilation syndrome
290.0
Senile dementia, uncomplicated
290.10–290.13
Presenile dementia
290.20–290.21
Senile dementia
290.3
Senile dementia with delirium
290.40–290.43
Arteriosclerotic dementia
290.8–290.9
Senile psychotic conditions
291.0–291.5
Alcoholic psychoses
291.81
Alcohol withdrawal
291.89
Other specified alcohol-induced mental disorders
291.9
Unspecified alcohol-induced mental disorders
292.0
Drug withdrawal
292.11–292.12
Paranoid and/or hallucinatory states induced by drugs
292.2
Pathological drug intoxication
292.81–292.84
Other drug-induced mental disorders
292.89
Other specified drug-induced mental disorders
292.9
Unspecified drug-inducted mental disorder
293.0–293.1
Transient organic psychotic conditions
293.81–293.84
Other specified transient organic mental disorders
293.89
Other specified transient mental disorders due to conditions classified elsewhere, other
293.9
Unspecified transient mental disorder in conditions classified elsewhere
294.0
Amnestic disorder in conditions classified elsewhere
294.10–294.11
Dementia in conditions classified elsewhere
294.8–294.9
Other organic psychotic conditions (chronic)
295.00–295.05
Schizophrenic disorders, simple type
295.10–295.15
Schizophrenic disorders, disorganized type
295.20–295.25
Schizophrenic disorders, catatonic type
295.30–295.35
Schizophrenic disorders, paranoid type
295.40–295.45
Schizophrenic disorders, acute schizophrenic episode
295.50–295.55
Schizophrenic disorders, latent schizophrenia
295.60–295.65
Schizophrenic disorders, residual schizophrenia
295.70–295.75
Schizophrenic disorders, schizo-affective type
295.80–295.85
Schizophrenic disorders, other specified types of schizophrenia
295.90–295.95
Schizophrenic disorders, unspecified schizophrenia
296.00–296.05
Manic disorder, single episode
296.10–296.15
Manic disorder, recurrent episode
296.20–296.25
Major depressive disorder, single episode
296.30–296.35
Major depressive disorder, recurrent episode
296.40–296.45
Bipolar affective disorder, manic
296.50–296.55
Bipolar affective disorder, depressed
296.60–296.65
Bipolar affective disorder, mixed
296.7
Bipolar I disorder, most recent episode (or current) unspecified
296.80–296.82
Manic-depressive psychosis, other and unspecified
296.89
Other and unspecified bipolar disorders, other
296.90
Unspecified episodic mood disorder
296.99
Other specified episodic mood disorder
297.0–297.3
Paranoid states (Delusional disorders)
297.8–297.9
Paranoid states (Delusional disorders)
298.0–298.4
Other non-organic psychoses
298.8–298.9
Other non-organic psychoses
299.00–299.01
Infantile autism
299.10–299.11
Disintegrative psychosis
299.80–299.81
Other specified early childhood psychoses
Note: Use of the diagnosis codes in the section above must be representative of the patient’s significant organic brain syndrome/dementia (with confusion or combative behavior) or psychotic condition.
300.00–300.02
Anxiety state
300.09
Other anxiety states
300.10
Hysteria, unspecified
Note: Use of the diagnosis codes in the section above must be representative of the patient’s severe anxiety, hysteria or panic attack condition supported by the need for and responses to sedative medication(s).
300.20–300.23
Phobic disorders
300.29
Other isolated or specific phobias
Note: Use of the diagnosis codes in the section above should represent that the patient has a severe phobic condition.
304.00–304.03
Opioid type dependence
304.10–304.13
Barbiturate and similarly acting sedative or hypnotic dependence
304.20–304.23
Cocaine dependence
304.30–304.33
Cannabis dependence
304.40–304.43
Amphetamine and other psychostimulant dependence
304.50–304.53
Hallucinogen dependence
304.60–304.63
Other specified drug dependence
304.70–304.73
Combinations of opioid type drug with any other
304.80–304.83
Combinations of drug dependence excluding opioid type drug
304.90–304.93
Unspecified drug dependence
Note: Use of the diagnosis codes in the section above must be representative of the patient’s drug dependency acute, detoxification state) condition.
305.00–305.02
Alcohol abuse
Note: Use of the diagnosis codes in the section above must be representative of the patient’s acute drunken condition.
305.20–305.22
Cannabis abuse
305.30–305.32
Hallucinogen abuse
305.40–305.42
Barbiturate and similarly acting sedative or hypnotic abuse
305.50–305.52
Opioid abuse
305.60–305.62
Cocaine abuse
305.70–305.72
Amphetamine or related acting sympathomimetic abuse
305.80–305.82
Antidepressant type abuse
Note: Use of the diagnosis codes in the section above must be representative of the patient’s drug abuse (acute, detoxification state) condition.
318.1-318.2
Other specified mental retardation
319
Unspecified mental retardation
324.0
Intracranial abscess
327.23
Obstructive sleep apnea
331.0
Alzheimer’s disease
332.0–332.1
Parkinson’s disease
Note: Use of the diagnosis codes in the section above must be representative of the patient’s condition.
335.20
Amyotrophic lateral sclerosis (ALS)
340
Multiple sclerosis
Note: Use of the diagnosis code above would be indicative of the patient’s having significant neurological impairment due to multiple sclerosis.
343.9
Infantile cerebral palsy, unspecified
Note: Use of the diagnosis code above must be representative of the patient’s condition.
345.00–345.01
Generalized non-convulsive epilepsy
345.10–345.11
Generalized convulsive epilepsy
345.2–345.3
Epilepsy
345.40–345.41
Partial epilepsy, with impairment of consciousness
345.50–345.51
Partial epilepsy, without mention of impairment of consciousness
345.60–345.61
Infantile spasms
345.70–345.71
Epilepsia partialis continua
345.80–345.81
Other forms of epilepsy
345.90–345.91
Epilepsy, unspecified
Note: Use of the diagnosis codes in the section above must be representative of the patient’s seizure disorder condition requiring appropriate antiepileptic medication.
358.00
Myasthenia gravis without (acute) exacerbation
362.29
Other non-diabetic proliferative retinopathy
362.52
Age-related macular degeneration
362.54
Macular hole
362.56
Macular pucker
391.0–391.2
Rheumatic fever with heart involvement
Note: Use of the diagnosis codes in the section above must be representative of the patient’s having an acute and unstable condition related to acute rheumatic cardiac disease.
394.0–394.2
Diseases of mitral valve
394.9
Other and unspecified mitral valve diseases
397.9
Rheumatic diseases of endocardium, valve unspecified
Note: Use of the diagnosis codes in the section above must be representative of the patient’s valvular heart disease condition (acute, symptomatic) supported by medical treatment and cardiac medications.
401.0
Malignant hypertension
401.9
Essential hypertension, unspecified
Note: Use of the diagnosis code above must be representative of the patient’s condition (systolic pressure over 180 or diastolic over 110 and on more than two antihypertensive medications).
402.00–402.01
Hypertensive heart disease, malignant
402.10–402.11
Hypertensive heart disease, benign
402.90–402.91
Hypertensive heart disease, unspecified
Note: Use of the diagnosis codes in the section above must be representative of the patient’s having an acute and unstable condition requiring multiple medications.
403.01–403.11
Hypertensive kidney disease
404.00–404.03
Hypertensive heart and kidney disease, malignant
404.11–404.13
Hypertensive heart and kidney disease, benign
404.91–404.93
Hypertensive heart and kidney disease, unspecified
405.01
Secondary hypertension, malignant renovascular
405.91
Secondary hypertension, unspecified renovascular
410.00–410.02 begin_of_the_skype_highlighting            00–410.02      end_of_the_skype_highlighting
Acute myocardial infarction, of anterolateral wall
410.10–410.12
Acute myocardial infarction, of other anterior wall
410.20–410.22
Acute myocardial infarction, of inferolateral wall
410.30–410.32
Acute myocardial infarction, of inferoposterior wall
410.40–410.42
Acute myocardial infarction, of other inferior wall
410.50–410.52
Acute myocardial infarction, of other lateral wall
410.60–410.62
Acute myocardial infarction, true posterior wall infarction
410.70–410.72
Acute myocardial infarction, subendocardial infarction
410.80–410.82
Acute myocardial infarction, of other specified sites
410.90–410.92
Acute myocardial infarction, unspecified site
411.0–411.1
Other acute and subacute forms of ischemic heart disease
411.81
Acute coronary occlusion without myocardial infarction
411.89
Other acute and subacute forms of ischemic heart disease
Note: Use of the diagnosis codes in the section above must be representative of the patient’s acute and unstable condition.
412
Old myocardial infarction
Note: Use of the diagnosis code above must be representative of the patient’s acute and unstable (e.g., multiple medications) ischemic heart disease/condition.
413.0–413.1
Angina pectoris
413.9
Other and unspecified angina pectoris
414.00–414.07 begin_of_the_skype_highlighting            00–414.07      end_of_the_skype_highlighting
Coronary atherosclerosis
414.10–414.12
Aneurysm and dissection of heart
414.19
Aneurysm of heart, other
414.2–414.3
Other forms of chronic ischemic heart disease
414.8–414.9
Other specified forms of chronic ischemic heart disease
Note: Use of the diagnosis codes in the section above must be representative of the patient’s condition.
415.0
Acute cor pulmonale
416.0
Primary pulmonary hypertension
416.2
Chronic pulmonary embolism
416.9*
Chronic pulmonary heart disease, unspecified
Note: Use of the diagnosis codes in the section above must be representative of the patient’s severe pulmonary condition.
420.0
Acute pericarditis in diseases classified elsewhere
420.90–420.91
Other and unspecified acute pericarditis
420.99
Other acute pericarditis
421.0–421.1
Acute and subacute endocarditis
421.9
Acute endocarditis, unspecified
422.0
Acute myocarditis in diseases classified elsewhere
422.90–422.93
Acute myocarditis
422.99
Other acute myocarditis
423.0–423.2
Other diseases of pericardium
423.8–423.9
Other diseases of pericardium
424.0–424.3
Other diseases of endocardium
424.90–424.91
Endocarditis, valve unspecified
424.99
Other endocarditis, valve unspecified
Note: Use of the diagnosis codes in the section above must be representative of the patient’s acute and unstable heart disease/condition requiring multiple medications.
425.0–425.5
Cardiomyopathy
425.7–425.9
Cardiomyopathy
Note: Use of the diagnosis codes in the section above must be representative of the patient’s severely impaired condition requiring multiple medications.
426.0
Conduction disorders, atrioventricular block, complete
426.10–426.13
Conduction disorders, atrioventricular block, other and unspecified
426.2–426.4
Conduction disorders
426.50–426.54
Conduction disorders, bundle branch block, other and unspecified
426.6–426.7
Conduction disorders
426.81–426.82
Other specified conduction disorders
426.89
Conduction disorders, other specified
426.9
Conduction disorders, unspecified
Note: Use of the diagnosis codes in the section above must be representative of the patient’s significant life threatening arrhythmia condition, such as ventricular rhythms.
427.0–427.2
Cardiac dysrhythmias
427.31–427.32
Atrial fibrillation and flutter
427.41–427.42
Ventricular fibrillation and flutter
427.5
Cardiac arrest
427.60–427.61
Premature beats
427.69
Other premature beats
427.81
Sinoatrial node dysfunction
427.89
Other specified cardiac dysrhythmias
Note: Use of the diagnosis codes in the section above must be representative of the patient’s significant arrhythmic condition, supported by history and diagnosis and use of appropriate treatment.
428.0–428.1
Heart failure
428.20–428.23
Systolic heart failure
428.30–428.33
Diastolic heart failure
428.40–428.43
Combined systolic and diastolic heart failure
428.9
Heart failure, unspecified
Note: Use of the diagnosis codes in the section above must be representative of the patient’s significant heart failure condition supported by the patient being on pulmonary and/or cardiac medications.
430
Subarachnoid hemorrhage
431
Intracerebral hemorrhage
432.0–432.1
Other and unspecified intracranial hemorrhage
433.00–433.01 begin_of_the_skype_highlighting            00–433.01      end_of_the_skype_highlighting
Occlusion and stenosis of basilar artery
433.10–433.11
Occlusion and stenosis of carotid artery
433.20–433.21
Occlusion and stenosis of vertebral artery
433.30–433.31
Occlusion and stenosis of multiple and bilateral precerebral arteries
433.80–433.81
Occlusion and stenosis of other specified precerebral arteries
433.90–433.91
Occlusion and stenosis of unspecified precerebral arteries
434.00–434.01 begin_of_the_skype_highlighting            00–434.01      end_of_the_skype_highlighting
Occlusion of cerebral arteries, thrombosis
434.10–434.11
Occlusion of cerebral arteries, embolism
434.90–434.91
Occlusion of cerebral arteries, unspecified
435.0–435.3
Transient cerebral ischemia
435.8–435.9
Transient cerebral ischemia
436
Acute, but ill-defined, cerebrovascular disease
437.0–437.9
Other and ill-defined cerebrovascular disease
Note: Use of the diagnosis codes in the section above must be representative of the patient’s acutely impaired condition supported by diagnosis and treatment.
490
Bronchitis, not specified as acute or chronic
492.8
Other emphysema
496
Chronic airway obstruction, not elsewhere classified
500
Coal workers' pneumoconiosis
501
Asbestosis
502
Pneumoconiosis due to other silica or silicates
503
Pneumoconiosis due to other inorganic dust
504
Pneumonopathy due to inhalation of other dust
505
Pneumoconiosis, unspecified
506.0–506.4
Respiratory conditions due to fumes and vapors
506.9
Unspecified respiratory conditions due to fumes and vapors
508.0–508.1
Respiratory conditions due to other specified external agents
508.8–508.9
Respiratory conditions due to other specified external agents
510.0
Empyema with fistula
510.9
Empyema without mention of fistula
511.0
Pleurisy without mention of effusion or current tuberculosis
511.81
Malignant pleural effusion
511.89
Other specified forms of effusion, except tuberculous
511.9
Unspecified pleural effusion
512.0–512.1
Pneumothorax
513.0
Abscess of lung
518.0–518.5
Other diseases of lung
518.7
Transfusion related acute lung injury (TRALI)
518.81–518.82
Other diseases of lung
Note: Use of the diagnosis codes in the section above must be representative of the patient’s condition.
570
Acute and subacute necrosis of liver
571.0–571.3
Chronic liver disease and cirrhosis
571.40–571.42
Chronic hepatitis
571.49
Chronic hepatitis, other
571.5–571.6
Chronic liver disease and cirrhosis
571.8
Other chronic non-alcoholic liver disease
572.0–572.4
Liver abscess and sequelae of chronic liver disease
572.8
Other sequelae of chronic liver disease
577.0–577.1
Diseases of pancreas
Note: Use of the diagnosis codes in the section above must be representative of the patient’s hepatic failure condition (serum bilirubin greater than 3).
578.9
Hemorrhage of gastrointestinal tract, unspecified
Note: Use of the diagnosis code above must be representative of massive gastrointestinal bleeding (e.g., more than 500 cc. of acute blood loss).
584.5–584.9
Acute renal failure
585.4–585.6
Chronic kidney disease (CKD)
586
Renal failure, unspecified
Note: Use of the diagnosis codes in the section above must be representative of the patient’s condition as acute renal failure or end stage renal disease on a dialysis program (serum creatinine level greater than 2).
745.5
Ostium secundum type atrial septal defect
780.1
Hallucinations
Note: Use of the diagnosis code above must be representative of the patient’s condition (supported by history and use of appropriate sedative medication).
780.31–780.33
Febrile convulsions
780.39
Other convulsions
Note: Use of the diagnosis codes in the section above must be representative of the patient’s unstable condition requiring multiple medications.
785.50–785.52
Shock without mention of trauma
785.59
Other shock without trauma
Note: Use of the diagnosis codes in the section above must be indicative of systolic pressure under 90 mmHg.
786.1
Stridor
995.0–995.1
Certain adverse effects not elsewhere classified
995.20–995.22
Other and unspecified adverse effect of drug, medicinal and biological substance
995.27
Other drug allergy
995.29
Unspecified adverse effect of other drug, medicinal and biological substance
995.3–995.4
Certain adverse effects not elsewhere classified
995.60–995.69
Anaphylactic shock due to adverse food reaction
V14.4–V14.6
Personal history of allergy to medicinal agents
V46.2
Use of supplemental oxygen
V58.69
Long term use of medication
Note: With V58.69, the medication, duration of use and dosage must be maintained in the medical record.
V44.0
Tracheostomy
Note: Providers should continue to submit ICD-9-CM diagnosis codes without decimals on their claim forms and electronic claims.
Diagnoses That Support Medical Necessity
Additional diagnoses that do not have a fully descriptive ICD-9-CM code are listed below. By using the diagnosis code(s) listed, the medical records must reflect the conditions as described.
  • For combative patients, use ICD-9-CM code 312.9.
  • For patients with low pain thresholds or who suffer severe pain, use ICD-9-CM code 997.00.
  • For intraoperative expansion of procedure, use ICD-9-CM code 998.9.
  • For any condition in a pediatric patient, Medicare eligible and younger than 12 years of age, use ICD-9-CM code 999.9.
If MAC is used for these reasons, clinical records must be available upon request that justify the need for MAC.
ICD-9-CM Codes That DO NOT Support Medical Necessity
N/A
Diagnoses That DO NOT Support Medical Necessity
All diagnoses not listed in the “ICD-9-CM Codes That Support Medical Necessity” section of this LCD.
Documentation Requirements
Documentation supporting medical necessity should be legible, maintained in the patient’s medical record and made available to Medicare upon request.
Hospital, outpatient, ASC or office records should clearly document the reason for the MAC (e.g., the patient’s condition that requires the appropriate anesthesia; indications the procedure performed was deep, complex, complicated or markedly invasive). A history and physical exam including progress notes should also be available to Medicare if a review is necessary.

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