Anesthesia for Pain Management Procedures

The use of moderate or deep sedation, general anesthesia and Monitored Anesthesia Care (MAC) is rarely indicated for pain management procedures and therefore is not considered reasonable and necessary.

The American Society of Anesthesiologist (ASA) provides guidelines for anesthetic care during interventional pain procedures for adults, stating that when sedation is provided during the performance of pain procedures it is important that the patient can be responsive during critical portions of the procedure to report potential procedure related paresthesia, acute changes in pain intensity or function for potential toxicity. 

The committee opinion states that interventional pain procedures generally only require local anesthetic however patients may elect to also receive supplemental sedation but must remain conscious. They state: “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.”

The ASA provides definitions on the continuum of the depth of sedation. Minimal sedation anxiolysis is defined as a drug-induced state during which patients respond normally to verbal commands. Although cognitive function and physical coordination may be impaired, airway reflexes, and ventilatory and cardiovascular functions are unaffected.³⁶ Progressing depth of sedation beyond minimal sedation are moderate or “conscious” sedation, deep sedation and general anesthesia. Monitored Anesthesia Care or “MAC” is not a depth of sedation, but a specific anesthetic service allowing a deeper level of analgesia than can be provided by moderate sedation.

Even in patients with a needle phobia and procedure anxiety can be managed with oral anxiolytics. In exceptional and unique cases, documentation must clearly establish the need for Monitored Anesthesia Care or any sedation in the specific patient. Radiofrequency ablation, which requires the patient to remain motionless for prolonged periods of time or remain in a painful position may require moderate sedation or an anesthesia care team.

The billing of moderate or deep sedation, general anesthesia, or MAC during a pain management procedure other than radiofrequency ablation will be denied. Frequent reporting of these services together may trigger focused medical review. 

References

1. LCD — Epidural Steroid Injections for Pain Management (L38994)
2. LCD — Facet Joint Interventions for Pain Management (L38765)