Anesthesia Procedures - Claim Documentation Requirements

Claims submitted with the procedure codes listed below should be accompanied by clinical notes when anesthesia services are performed on patients who have a high risk medical or age-related diagnosis.

I. Anesthesia codes that require clinical information for patients who are considered high-risk.

Providers should submit the pre-anesthesia evaluation and the anesthesia report with their claim which documents the rationale for the use of general anesthesia in high risk patients or clinical history which supports a high risk condition.

II. High Risk Indications

• Acute septicemia
• Diabetes, with glucose level greater than 300
• Severe metabolic disorders (e.g., thyrotoxicosis, adrenal gland disorders)
• Electrolyte imbalance (sodium, potassium, and calcium levels outside normal limits)
• Morbid obesity (BMI greater than 40 or BMI greater than 35 with comorbid medical conditions (refractory hypertension, obstructive sleep apnea, coronary heart disease, type 2 diabetes)
• Organic brain syndrome/dementia (with confusion, combative behavior and various types of psychoses)
• Severe anxiety, hysteria, panic attacks for which the patient has received treatment and that cannot be easily controlled with appropriate medications (e.g., anxiolytics)
• Phobic disorders
• Various types of drug dependency or drug abuse (acute detoxification state)
• Alcohol abuse (current, continuous or episodic)
• Intracranial abscess
• Alzheimer's disease
• Seizure disorders (on appropriate anti-epileptic medication)
• Rheumatic fever with cardiac involvement
• Valvular heart disease or disorders
• Malignant hypertension, greater than 110 diastolic or greater than 180 systolic and on two or more hypertensive medications)
• Hypertensive heart disease (patient is acute, unstable and on multiple medications)
• Hypertensive heart and renal disease
• Acute myocardial infarction
• Other forms of acute and subacute forms of ischemic heart disease
• Angina pectoris
• Other forms of chronic ischemic heart disease
• Acute and chronic pulmonary disease (severe)
• Other forms of heart disease such as pericarditis, endocarditis, myocarditis, or cardiomyopathy
• Life threatening arrhythmias (e.g., tachycardia, ventricular fibrilation)
• Heart failure
• Acute cerebrovascular disease
• COPD and allied conditions
• Pneumoconioses or asbestosis
• Respiratory conditions due to chemical fumes and vapors and other external causes (e.g., radiation)
• Pneumothorax
• Pulmonary collapse, emphysema, edema, eosinophyilia or insufficiency
• Hepatic failure, with bilirubin greater than 3
• Massive gastrointestinal bleeding, greater than 500cc blood loss by history
• Renal failure, acute or end-stage renal disease, or on dialysis, with creatinine greater than 2
• Active hallucinations
• Convulsions (unstable patient on multiple medications)
• Hypotension or shock, with systolic pressure greater than 90
• Danger of airway compromise
  • History of sleep apnea or stridor; or
  • Persons with dysmorphic facial features, such as Pierre-Robin syndrome or Down syndrome; or
  • Persons with oral abnormalities, such as small opening (less than 3 cm in adult); protruding incisors; high arched palate; macroglossia; tonsillar hypertrophy; or a poorly visualized or non-visible uvula; or
  • Persons with neck abnormalities, such as obesity involving the neck and facial structures, short neck, limited neck extension, spinal cord instability, decreased hyoid-mental distance (less than 3 cm in adult), neck mass, cervical spine disease or trauma, disorders of cranial nerves IX or X, tracheal deviation, or advanced rheumatoid arthritis; or
  • Persons with jaw abnormalities, such as micrognathia, retrognathia, trismus, or significant malocclusion; or
• Severe allergic reactions
• Patients with very low pain thresholds with a history of inability to complete endoscopic or other procedures
• Pediatric patients through age 11
• Tracheostomy
• Combative patients (include the appropriate diagnosis of psychosis or drug induced behavior)

If benefits are denied because the service does not meet HMSA guidelines for coverage, participating anesthesiologists will be required to adjust their charges and may not bill the HMSA member. However, if the provider has explained to the member that the service may not be covered, and the member has indicated that he or she wants the services performed, the patient should complete and sign HMSA’s Acknowledgement of Financial Responsibility.  Modifier code GA should be appended to the CPT code for the anesthesia service and HMSA will process the claim to show that the member owes the provider for the denied charges.  A copy of the signed waiver must be kept in the patient's medical record.  HMSA reserves the right to audit claims using modifier GA and may ask to review medical records for proper documentation.

Some surgical procedures have medical policies that require precertification. If precertification has not been obtained for the service, the surgery and anesthesia will be subject to medical review. If the surgery is not covered, the anesthesia is also not covered.

Please be sure to use the most up-to-date industry-standard procedure, revenue, and diagnosis codes from the current CPT ®'', HCPCS Level II, and ICD-10-CM manuals, as recommended by the American Medical Association (AMA), the Centers for Medicare & Medicaid Services (CMS), and the American Hospital Association.

** Codes may not be all inclusive as the AMA and CMS code updates may occur more frequently.