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September 1, 2015

BCBS Policy Changes That Affect Anesthesia & Gastroenterology

September 1, 2015

Blue Cross Blue Shield of Alabama recently released new guidelines for surgical procedures and Monitored Anesthesia Care (MAC).  These new guidelines are geared towards Gastroenterologist and MAC sedation with endoscopies and colonoscopies.  As you are probably aware over the last few years there has been a large increase in utilizing MAC for these procedures.  BCBSAL’s new guideline appears to offset the total BCBSAL out of pocket expense.

Effective December 1, 2015 the surgeon should include a new modifier (47) for all cases performed with self-administered moderate (conscious) sedation.  The modifier 47 allows for the current / higher reimbursement.

If MAC is administered by an anesthesiologist or CRNA the modifier 47 should NOT be used.  The surgeon will be reimbursed a lower rate approximately $90-$165 with an average impact of $130 (per updated PMD fee schedule) less than the current payment.  Payments to the anesthesia provider will be unaffected; the anesthesia provider will be reimbursed at the current rate.

According to BCBSAL the CPT code definition includes anesthesia in the procedure thus the need to separate the two. Essentially, for cases utilizing MAC, BCBSAL is taking money from the Gastroenterologist to help cover the cost of the anesthesia provider.

It remains unclear if these new guidelines will impact the anesthesia reimbursements for P1 and P2 patients.  I am under the impression that the existing medical policies will still apply. 

Medical Business Management is the industry leader in anesthesia billing policies and procedures. We work with our clients to help maintain compliance and maximize reimbursement. If you have questions about the guidelines, please contact us today.


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