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Network Matters
News and Information for the
Harvard Pilgrim Health Care Network

November 2018

Billing Monitored Anesthesia Care Policy for Screening Colonoscopies for Commercial Members

Under our commercial Monitored Anesthesia Care (MAC) for Gastrointestinal Endoscopic Procedures policy, Harvard Pilgrim covers MAC for screening colonoscopies without cost sharing for members, in keeping with provisions of the Patient Protection and Affordable Care Act.

To ensure that these claims are processed correctly, it is important to bill MAC anesthesia for screening colonoscopies for commercial members with CPT code 00812 (Anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum; screening colonoscopy) regardless of findings — including in cases in which polyps are discovered and surgically removed.

Keep in mind that the MAC policy applies for CPT code 00811 (Anesthesia for lower intestinal endoscopic procedures, endoscopy introduced distal to duodenum; not otherwise specified), as well as combined upper and lower gastrointestinal procedures (00813) and upper gastrointestinal endoscopic procedures (00731 and 00732). For these codes, Harvard Pilgrim considers MAC for GI endoscopy medically necessary only when the policy criteria are met, and member cost sharing applies for MAC performed with colonoscopies that are not considered preventive screenings.

For more information, please refer to the updated Monitored Anesthesia Care for Gastrointestinal Endoscopic Procedures Medical Policy.

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