CurrentAlliance Health (LME/MCO)Policy 1L-1
Anesthesia Services
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Defines coverage, eligibility, and payment-related rules for anesthesia services under NC Medicaid (beneficiaries and providers), including types of anesthesia, time-based billing, EPSDT exceptions for beneficiaries under 21, and related administrative requirements.
Policy Summary
PayerAlliance Health (LME/MCO)
PolicyAnesthesia Services
Policy CodePolicy 1L-1
Change TypeNo material change
Effective DateOct 1, 2003
Last ReviewAug 15, 2023
Next Review DateN/A
Key ActionWhen prior approval is required the surgeon must obtain and submit the prior approval request and supporting records to the DHHS Utilization Review Contractor.
SourceLink
POLICY UPDATE CHANGES
No material clinical or coverage changes in this revision.
EPSDT exception appliesEPSDT exception
Time-based billing requiredTime billing
May be requiredPrior approval
Patient-controlled anesthesiaNot covered
Max 4Concurrent direction
50%AA/AA payment
Coverage Criteria and Limits for Anesthesia Services
Coverage criteria for anesthesia services
General coverage criteria and EPSDT note apply:
Medicaid covers the procedure, product, or service when medically necessary and individualized to the beneficiary's symptoms or confirmed diagnosis, and not in excess of the beneficiary's needs.
The procedure, product, or service can be safely furnished and no equally effective, more conservative, or less costly treatment is available statewide.
The procedure, product, or service is furnished in a manner not primarily intended for the convenience of the beneficiary, the beneficiary's caretaker, or the provider.
EPSDT (beneficiaries under 21) may exceed policy limits when medically necessary to correct or ameliorate a condition; refer to Subsection 2.2.1 regarding EPSDT exception.
Note: Prior approval requirements still apply when applicable.
Anesthesia time billing requires the provider to be in continuous actual physical presence for billed time; anesthesia time begins when the provider starts preparing the patient for anesthesia care and ends when the provider is no longer in personal attendance.
Anesthesia coverage criteria and limits
Medicaid covers anesthesia services when medically necessary and meeting general criteria; the policy defines items included in the global package, items billable separately, and specific exclusions:
General, regional, and Monitored Anesthesia Care (MAC) are considered a global package that includes the usual preoperative and postoperative visits, anesthesia services during the procedure, administration of IV fluids including blood/products, intra-operative laboratory evaluations, and routine monitoring services (e.g., ECG, temperature, blood pressure, pulse oximetry, capnography, end-tidal gas analysis, mass spectrography, bispectral EEG, transcranial Doppler) and their interpretation. These services are not reimbursed separately unless unrelated and billed with modifier 59.
Monitoring services not included in global package (may be billed separately with modifier 59):
- Pulmonary artery catheter insertion.
- Central venous catheter insertion.
- Intra-arterial catheter insertion.
- Nerve blocks for postoperative pain relief (single injections and continuous catheters, including epidural, spinal, and peripheral nerve blockade).
- Ultrasound-guided central venous access and assisted peripheral nerve blockade.
- Transesophageal echocardiography (TEE) monitoring and interpretation.
Peripheral nerve blocks, plexus blocks, and epidural and caudal blocks administered for postoperative or intractable pain are covered (these are billable as indicated).
Local anesthesia that is an injection into cutaneous or subcutaneous tissue for a limited area is included in the procedure fee and is not separately reimbursable when performed by the operating physician.
Patient-controlled anesthesia is not covered.
Anesthesia coverage criteria and billing rules
Operational and billing rules, provider eligibility, and qualifying circumstances that determine allowable anesthesia claims:
To bill for medical direction the anesthesiologist must: perform the pre-anesthesia evaluation and exam; prescribe the anesthesia; participate personally in induction and emergence; ensure any part of the anesthesia plan not personally performed is performed by a qualified CRNA or anesthesiologist assistant; monitor the course of anesthesia at frequent intervals; remain physically present and available in the operating suite; and provide post-anesthesia care (or supervise qualified personnel providing it).
An anesthesiologist directing concurrent anesthesia may direct up to four surgical patients; while directing up to four patients the physician generally may not be involved in furnishing additional services that would prevent availability to the surgical patients; leaving the immediate area for more than short durations or devoting extensive time elsewhere converts services to supervisory (not reimbursable).
Only one follow-up code for daily hospital management of continuous epidural or subarachnoid drug administration is covered per day; that code includes related services performed that day (visit, removal/adjustment of catheter, dose calculation, drug administration).
For multiple procedures on the same date of service, reimbursement uses the base unit of the procedure with the highest base unit value and time units based on actual anesthesia time; medical records documenting codes/time are not required with the initial claim but must be provided upon request.
If returned to the OR after labor/delivery or cesarean to perform sterilization, report anesthesia CPT 00851 separately and include total time units; sterilization billed with delivery may be subject to cutback pricing but both services are allowed.
Qualifying circumstances (report as one additional unit in addition to the primary procedure) include: beneficiaries under 1 year and over 70 years of age (extreme age); anesthesia complicated by total body hypothermia when due to type of surgery; anesthesia complicated by controlled hypotension when due to type of surgery; and anesthesia complicated by an emergency where delay would significantly increase threat to life or body part.
Anesthesia stand-by services are covered for high-risk deliveries when the appropriate diagnosis code is used and no other anesthesia services are provided.
The global anesthesia package includes preoperative evaluation, prescription of anesthetic plan, routine intra-op monitoring and labs, IV fluids including blood, immediate postop care, and a postoperative visit when applicable; critical care E/M and ventilator management E/M are covered if extended care beyond immediate postop is required and must be billed separately with modifier 25 appended.
Anesthesia consultations must be requested by the attending or appropriate source and documented; routine preoperative visits are not consultations (Medicaid follows CPT E/M definitions).
Providers eligible to bill must meet Medicaid participation qualifications, have a signed DHHS Provider Administrative Participation Agreement, and bill only for services within their licensed scope of practice. CRNA, anesthesiologist assistant, and related qualification and supervision rules apply per referenced licensing regulations.
Billing and reimbursement criteria
Billing, claim form placement, modifier use, time/unit reporting, and reimbursement calculations for anesthesia services:
Claim form and block guidance: hospital professional charges for CRNA or AA are billed on the hospital's professional claim form; facility charges on UB-04 use revenue codes in the 37X range for anesthesia facility charges; CMS-1500 block 33 and block 24G instructions apply as specified for provider and attending numbers.
Modifiers: append QX when a CRNA is medically directed (on the CRNA claim), append QY or QK on the anesthesiologist claim when medically directing a CRNA/AA; append QZ when a CRNA performs the service without medical direction; append AD when more than four concurrent CRNA cases are supervised; AA indicates service personally performed by anesthesiologist; FP is used for sterilization procedures with ICD-10 Z30.2 as required.
Time reporting: report anesthesia time for general and monitored anesthesia services as 1 minute = 1 unit (enter anesthesia time in block 24G as '1 minute = 1 unit'). Time units are not recognized for codes 01967 and 01996 (these have a flat rate of 1 unit per occurrence). If the anesthesia provider is not in constant attendance due to surgical delay, billed time must be reduced to reflect actual time spent with the beneficiary.
Reimbursement calculation: For anesthesiologists personally performing the service use (Base units + time) x physician maximum allowed amount (use AA modifier). If the anesthesiologist medically directs a CRNA/AA, physician payment = (Base units + time) x 50% of physician maximum (use QY). If medically supervises >4 CRNAs, physician allowable is 45 base units per procedure and a one-time 15-minute block may be billed if documented (use AD).
CRNA and AA payment rules: If CRNA not medically directed, payment = (Base units + time) x CRNA maximum allowed amount (use QZ). If CRNA is medically directed by an anesthesiologist, payment = (Base units + time) x 50% of physician maximum (use QX). Anesthesiologist assistant reimbursement = (Base units + time) x 50% of physician maximum (no modifier).
Anesthesia billing and payment criteria for labor/delivery/sterilization
Special billing and payment rules for labor, delivery, and sterilization anesthesia services, including combination and cutback rules:
When sterilization is billed in addition to delivery (e.g., 01960, 01961, 01968), sterilization will have cutback pricing applied but both services will be allowed; when the beneficiary is returned to the OR after delivery/cesarean for sterilization report anesthesia CPT 00851 separately with total time units.
Payment formulas for providers: if the CRNA is not medically directed, payment = (Base units + time) x CRNA maximum allowed amount (use QZ). If the CRNA is medically directed by the anesthesiologist, payment = (Base units + time) x 50% of the physician maximum allowed amount (use QX).
Anesthesiologist assistant reimbursement = (Base units + time) x 50% of the physician maximum allowed amount (no modifier). If the anesthesia provider is not in constant attendance due to delay, billed time must be reduced to reflect actual time.
Specific combination code rules and time unit treatments:
- 01967 (neuraxial labor analgesia/anesthesia for planned vaginal delivery) uses a flat rate of 1 unit per occurrence (includes repeat subarachnoid needle placement and catheter replacement).
- 01968 (anesthesia for cesarean delivery following neuraxial labor) is reported separately in addition to the primary procedure and time units follow the standard time reporting (1 minute = 1 unit).
- 01960 and 01961 (anesthesia for vaginal delivery and cesarean delivery only) and codes such as 00840/00851 for intraperitoneal lower abdominal procedures may be used for sterilization procedures with ICD-10-CM diagnosis code Z30.2; cutback pricing applies when billed with delivery as described in Attachment B.
Codes, Time Definitions, Modifiers, and Unit Rules
Claims-related sections (codes, modifiers, billing units)mixed
| No codes listed |
Global-package vs Separately Billable Monitoringmixed
| global_package | General anesthesia, regional anesthesia, and MAC include pre/postoperative visits, intraoperative anesthesia, IV fluids including blood, intra-op labs, and usual monitoring; these are not reimbursed separately unless unrelated and billed with modifier 59. |
| separately_billable_monitors | Pulmonary artery catheter insertion; central venous catheter insertion; intra-arterial catheter insertion; nerve blocks for postoperative pain (single and continuous including epidural, spinal, peripheral); ultrasound-guided central venous access and assisted peripheral nerve blockade; transesophageal echocardiography (TEE) — billed separately with modifier 59. |
Epidural catheter follow-upCPTCovered
| daily hospital management of continuous epidural or subarachnoid drug administration | Only one follow-up code (daily hospital management of continuous epidural or subarachnoid drug administration performed after insertion of an epidural or subarachnoid catheter) is covered per day; includes all related services performed that day (visit, removal/adjustment of catheter, dose calculation, and drug administration). |
Sterilization after deliveryCPTCovered
| 00851 | Anesthesia CPT code 00851 reported separately with total time units when beneficiary is returned to OR after labor/delivery or cesarean to perform subsequent sterilization; applies to all sterilization procedures performed under general, regional, or MAC. Also: sterilization procedures billed must be accompanied by ICD-10-CM diagnosis code Z30.2 and modifier FP; sterilization reimbursement may have cutback pricing when billed with labor and delivery (see Attachment A). |
Anesthesia-specific modifiersModifier
| QX | Modifier appended to CRNA CPT code when CRNA is medically directed (used on CRNA claim). |
| QY | Modifier appended by the anesthesiologist when medically directing CRNA/AA (anesthesiologist claim). |
| QK | Modifier (alternate) appended by the anesthesiologist when medically directing CRNA/AA (anesthesiologist claim). |
| QZ | Modifier appended to CPT code when CRNA performs service without medical direction (use when not medically directed). |
| AA | Modifier indicating service personally performed by anesthesiologist (used for services without medical direction by others). |
| AD | Modifier indicating medical supervision of CRNA for more than four concurrent cases (used when applicable). |
| FP | Modifier to append for sterilization procedures (must be billed with ICD-10-CM diagnosis code Z30.2). |
Labor/Delivery/Sterilization anesthesia codesCPTCovered
| 01967 | Neuraxial labor analgesia/anesthesia for planned vaginal delivery; flat rate 1 unit per occurrence (includes any repeat subarachnoid needle placement and drug injection and/or any necessary replacement of an epidural catheter during labor). |
| 01968 | Anesthesia for cesarean delivery following neuraxial labor analgesia/anesthesia (list separately in addition to primary procedure performed); time units reported as 1 minute = 1 unit where applicable. |
| 01960 | Anesthesia for vaginal delivery only (time units billed as 1 minute = 1 unit). |
| 01961 | Anesthesia for cesarean delivery only (time units billed as 1 minute = 1 unit). |
| 00840 | Anesthesia for intraperitoneal procedures in lower abdomen including laparoscopy; not otherwise specified (used for sterilization/tubal procedures; cutback pricing applies when billed with delivery). |
| 00851 | Anesthesia for intraperitoneal procedures in lower abdomen including laparoscopy; tubal ligation/transaction (report separately with total time units if returned to OR after delivery); cutback pricing applies when billed with delivery; must be billed with ICD-10-CM code Z30.2 and modifier FP for sterilization procedures. |
| 01969 | Anesthesia for cesarean hysterectomy following neuraxial labor analgesia/anesthesia (list separately in addition to primary procedure performed); time units billed as 1 minute = 1 unit. |
Anesthesia time definition
DefinitionTime begins when the anesthesiologist, resident, CRNA, or anesthesiologist assistant begins to prepare the patient for anesthesia care in the operating room or equivalent area and ends when that provider is no longer in personal attendance.
Continuous presenceProvider must be in constant attendance of the patient during the time billed; billed time requires continuous actual physical presence.
Scope of providersApplies to anesthesiology physician, resident, CRNA (per 21 NCAC 36.0226), or anesthesiologist assistant supervised by an anesthesiologist.
Anesthesia time definition
Start/End pointsStarts when the provider begins preparing the patient for anesthesia care and ends when the provider is no longer in personal attendance (patient may be safely placed under postoperative supervision).
Attendance requirementThe anesthesiologist, resident, CRNA, or anesthesiologist assistant must be in constant attendance of the patient during billed time.
Applicable settingsPreparation may occur in the operating room or equivalent area.
Concurrent direction limit
Concurrent limitAn anesthesiologist may direct the administration of anesthesia to not more than four surgical patients concurrently.
Permitted concurrent activitiesWhile directing concurrent cases, brief activities (e.g., addressing a short emergency, administering an epidural for labor pain, periodic obstetrical monitoring) do not ordinarily diminish the physician's control for medical direction.
Leaving immediate areaIf the physician leaves the immediate area for other than short durations or is unavailable to respond, the services become supervisory and are not reimbursable as medical direction.
Obstetric anesthesia time limit
Maximum payable minutesMaximum of 180 time units (minutes) payable per date of service for specified obstetric anesthesia procedures (e.g., anesthesia for vaginal delivery only; cesarean delivery only; anesthesia for cesarean delivery following neuraxial labor analgesia/anesthesia; cesarean hysterectomy following neuraxial labor analgesia/anesthesia; urgent hysterectomy following delivery).
Exceeding limitUnits billed exceeding 180 will be cut back; adjustment with medical records may be submitted for consideration of additional payment.
DocumentationDocumentation must support all units billed and services rendered when requesting additional payment beyond 180 units.
Flat rate and time unit rules
Flat-rate codesCertain neuraxial labor codes (e.g., 01967 and some C-section hysterectomy combinations) use a flat 1 unit per occurrence rather than time units.
Time unit reportingFor all general and monitored anesthesia services providers must report time as 1 minute = 1 unit; time units are not recognized for codes specified as flat-rate.
Cutback pricingWhen sterilization is billed in addition to delivery (e.g., 01960, 01961, 01968), cutback pricing applies to the sterilization component though both services will be allowed.
Provider Responsibilities, Prior Approval, and Billing Procedures
Prior Authorization
Prior approval requirement (EPSDT does not waive)
EPSDT does not waive any prior approval requirement. If a service, product, or procedure requires prior approval, the fact that the beneficiary is under 21 years of age does NOT eliminate that requirement. See the NCTracks Provider Claims and Billing Assistance Guide and the EPSDT provider page for additional information: https://www.nctracks.nc.gov/content/public/providers/providermanuals.html and https://medicaid.ncdhhs.gov/.
Prior Authorization
Prior approval submission — surgeon responsibility
When a surgical procedure requires prior approval, it is the surgeon’s responsibility to obtain and submit the prior approval request and all supporting health records and documentation to the DHHS Utilization Review Contractor to demonstrate the beneficiary meets the applicable criteria.
Billing Rule
Medical direction billing requirements
To bill for medical direction, the anesthesiologist must be physically and personally involved in the care of the beneficiary simultaneously with the CRNA or anesthesiologist assistant and must: perform the pre‑anesthesia evaluation and exam; prescribe the anesthesia; participate personally in induction and emergence; ensure any parts not personally performed are performed by a qualified CRNA or anesthesiologist assistant; monitor the course of anesthesia at frequent intervals; remain physically present and available in the operating suite to provide diagnosis and treatment in an emergency; and provide post‑anesthesia care (directly or by a qualified provider under the anesthesiologist’s supervision).
Billing Rule
Multiple procedures reimbursement
When multiple surgical procedures occur on the same date of service, reimbursement is based on the procedure with the highest base unit value and uses time units based on the actual anesthesia time for the combined procedures. Medical records documenting the codes and times are not required at submission but must be provided upon request.
Prior Authorization
Anesthesia stand‑by coverage
Anesthesia stand‑by services are covered for high‑risk deliveries only when the appropriate diagnosis code is used and no other anesthesia services are provided. See Clinical Coverage Policy 1E‑5, Obstetrics, for additional guidance.
- Applicable when no other anesthesia services are performed and appropriate high‑risk delivery diagnosis coding is used
- Refer to Clinical Coverage Policy 1E‑5 for clinical criteria and coding guidance
Documentation Required
Documentation requirement for teaching anesthesiologists
Teaching anesthesiologists must document their presence during critical portions of care to receive an unreduced fee. When involved in concurrent cases with residents, the teaching anesthesiologist may bill usual base units and anesthesia time for the period they are present with the resident (including throughout pre‑ and post‑anesthesia care). Use the AA modifier to report such cases. Documentation of involvement must be sufficient to support payment and be available for review upon request.
- Use modifier AA when the teaching anesthesiologist personally performs the service without medical direction of a CRNA
- Document presence during induction, pre‑ and post‑anesthesia care, and other critical periods to support billed time and units
Billing Rule
CRNA reimbursement rules
CRNA reimbursement varies by whether medical direction is provided: if the CRNA performs the service without medical direction, the payment is (Base units + time) x CRNA maximum allowed amount and the QZ modifier must be appended. If the CRNA is medically directed by an anesthesiologist, payment is (Base units + time) x 50% of the physician maximum allowed amount and the QX modifier must be used. When more than four concurrent cases are supervised by an anesthesiologist, the AD modifier applies to the anesthesiologist (who is reimbursed 45 base units per supervised procedure and may bill a one‑time 15‑minute block if present at induction) and the CRNA must append QZ to the anesthesia CPT code.
- CRNA without medical direction: append QZ modifier; payment = (Base units + time) x CRNA max allowed
- CRNA with medical direction: append QX modifier; payment = (Base units + time) x 50% physician max allowed
- When >4 concurrent cases: anesthesiologist uses AD modifier and is reimbursed 45 base units per supervised procedure; CRNA appends QZ
Definitions and Terminology
Anesthesia services (included components)
Included componentsAnesthesia services include preanesthesia evaluation and prescription of an anesthetic plan, intraoperative anesthesia care, and immediate postanesthesia care with postoperative visit when applicable.
Monitoring and interventionsServices include routine monitoring (ECG, temperature, blood pressure, pulse oximetry, capnography, end-tidal gas analysis, bispectral EEG, transcranial Doppler), interpretation of intraoperative lab tests, and administration of IV fluids including blood and blood products.
Scope of anesthesia typesIncludes general anesthesia, regional anesthesia, and monitored anesthesia care (MAC).
Anesthesia time (billing definition)
Continuous presence requirementAnesthesia time requires continuous actual physical presence with the patient by the anesthesiology physician, resident, CRNA, or anesthesiologist assistant supervised by an anesthesiologist.
Start and end of timeTime starts when the provider begins preparing the patient for anesthesia care in the OR or equivalent area and ends when the provider is no longer in personal attendance.
Billing implicationProvider must be in constant attendance for billed time; if not in constant attendance due to delays, billed time must be reduced to reflect actual time spent.
Moderate (conscious) sedation distinction
Distinct serviceModerate (conscious) sedation is separate and distinct from anesthesia services and is governed by a different policy (see 1L-2).
Provider allowanceModerate sedation may be administered or supervised by non-anesthesia-credentialed providers provided the supervising physician is credentialed to provide moderate sedation at the practice site.
Billing/coverage noteRefer to the related policy for coverage and billing specifics for moderate sedation.
General anesthesia
DefinitionGeneral anesthesia is a controlled, reversible state of unconsciousness with partial or complete loss of protective reflexes, amnesia, and analgesia; may include muscle relaxation.
Clinical componentsIncludes administration/dosing of pharmacologic agents, intraoperative monitoring, treatment of adverse reactions, IV fluid/blood administration, intra-op lab interpretation, and critical care services when needed.
Presence requirementNecessitates continuous actual presence of an anesthesiologist, resident, CRNA, or supervised anesthesiologist assistant and includes preanesthetic exam and postoperative care.
Regional anesthesia
DefinitionRegional anesthesia produces loss of sensation or motor function to a region via central neuraxis (spinal, epidural, caudal), nerve plexi, or peripheral nerves.
Clinical dutiesRequires intra-operative monitoring, treatment of adverse physiological reactions, IV fluid/blood administration, and ability to convert to general anesthesia if necessary.
Presence requirementRequires continuous actual presence of an anesthesiologist, resident, CRNA, or supervised anesthesiologist assistant and includes preanesthetic exam and postoperative care.
Monitored Anesthesia Care (MAC)
DefinitionMonitored Anesthesia Care (MAC) involves continuous intra-operative monitoring in anticipation of the need for general anesthesia or an adverse physiological reaction.
Monitoring focusRequires careful and continuous evaluation of vital physiological functions and recognition/treatment of adverse changes.
Presence requirementNecessitates continuous actual presence of an anesthesiologist, resident, CRNA, or supervised anesthesiologist assistant and includes preanesthetic exam and postoperative care.
Local anesthesia
DefinitionLocal anesthesia is injection of local anesthetic into cutaneous and subcutaneous tissue providing loss of pain sensation to a limited area.
Billing noteAdministration of local anesthesia is included in the fee for the procedure and is not separately reimbursable when performed by the operating physician.
ScopeIncludes injections of local, field, or regional blocks performed by the operating physician as part of the procedure fee.
Medical direction
DefinitionMedical direction is the anesthesiologist's physical and personal involvement in the beneficiary's care simultaneously with a CRNA or anesthesiologist assistant when specific actions are performed.
Required actionsTo bill medical direction the anesthesiologist must perform pre-anesthesia evaluation, prescribe anesthesia, participate in induction and emergence, ensure qualified personnel perform other parts, monitor frequently, remain physically present and available in the operating suite, and provide post-anesthesia care.
DelegationAny part of the anesthesia plan not personally performed must be performed by a qualified CRNA or anesthesiologist assistant under the anesthesiologist's oversight.
Qualifying circumstances
Qualifying circumstances examplesExamples include extreme age (report for beneficiaries under 1 year and over 70 years), total body hypothermia, controlled hypotension, and emergency conditions.
ReportingThese conditions are reported as one additional unit in addition to the primary procedure and are not reported alone.
ApplicationApplied when anesthesia is provided under particularly difficult circumstances due to patient condition, operative conditions, or unusual risk factors.
Anesthesia time unit
Time unit definitionProviders must report anesthesia time for all general and monitored anesthesia services as 1 minute = 1 unit.
ExceptionsTime units are not recognized for certain codes specified as flat-rate (e.g., 01967, 01996); those use a flat 1 unit per occurrence.
Billing accuracyTime units are not rounded for the codes that require 1 minute = 1 unit; records must support units billed.
Base units
Base unitsBase units reflect procedure complexity and are used in reimbursement calculations (Base units + time) x conversion factor = payment component.
Anesthesiologist payment basisAnesthesiologist payment is calculated using base units plus time multiplied by the physician maximum allowed amount (conversion factor applies per policy provisions).
DocumentationAppropriate documentation must support the base units and time reported for reimbursement.
Medically directed CRNA
DefinitionMedically directed CRNA refers to a CRNA providing anesthesia services under the medical direction of an anesthesiologist, with billing and payment rules differing based on direction.
Payment implicationIf the CRNA is medically directed, payment = (Base units + time) x 50% of the physician maximum allowed amount (use QX modifier).
Documentation requirementMedical direction actions by the anesthesiologist must be documented to support billing as medically directed.
CRNA maximum allowed amount
CRNA maximum allowed amountWhen a CRNA performs the service without medical direction, payment = (Base units + time) x CRNA maximum allowed amount (use QZ modifier).
ModifiersUse QZ modifier when CRNA performs service without medical direction; use QX when medically directed by an anesthesiologist.
Supervision over 4 casesIf anesthesiologist supervises more than four concurrent cases, AD modifier indicates medical supervision and special reimbursement rules apply (anesthesiologist reimbursed 45 base units for each supervised procedure).
Anesthesiologist assistant
Definition and paymentAnesthesiologist assistant reimbursement = (Base units + time) x 50% of the physician maximum allowed amount (no modifier used).
Supervision requirementAn anesthesiologist assistant must be supervised by an anesthesiologist; time billed must be reduced if provider is not in constant attendance due to surgical delay.
Claiming noteAA modifier indicates the service was personally performed by the anesthesiologist when applicable; AA is also used per policy for specific billing contexts.
Cutback pricing
Cutback pricing definitionCutback pricing applies when sterilization is billed in addition to delivery; sterilization may be reduced while both services are allowed (see Attachment B).
ExamplesWhen sterilization is billed with delivery codes (01960, 01961, 01968) or with neuraxial labor analgesia/anesthesia (01967 combinations), cutback pricing applies to the sterilization component.
Flat-rate interplaySome neuraxial labor codes are flat-rate (e.g., 01967 = 1 unit) while associated sterilization codes may be subject to cutback pricing when billed concurrently.
Policy Summary
PayerAlliance Health (LME/MCO)
PolicyAnesthesia Services
Policy CodePolicy 1L-1
Change TypeNo material change
Effective DateOct 1, 2003
Last ReviewAug 15, 2023
Next Review DateN/A
Key ActionWhen prior approval is required the surgeon must obtain and submit the prior approval request and supporting records to the DHHS Utilization Review Contractor.
SourceLink
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