CurrentAlliance Health (LME/MCO)Policy 1L-1

Anesthesia Services

Defines Medicaid coverage, limitations, billing and prior approval requirements for anesthesia services (general, regional, monitored anesthesia care, pain management, local anesthesia), qualifying circumstances, provider eligibility, documentation, and claim submission rules for North Carolina Medicaid.

Policy Summary

PayerAlliance Health (LME/MCO)

PolicyAnesthesia Services

Policy CodePolicy 1L-1

Change TypeAmendment (08/15/2023)

Effective DateOct 1, 2003

Next Review Date

Key ActionWhen prior approval is required, the surgeon must obtain it and providers must maintain and provide documentation supporting anesthesia services on request.

SourceLink

POLICY UPDATE CHANGES

08/15/2023 Section 6.1: changed 'two' to 'four' anesthesia assistants at one time; Attachment A Section D Modifiers: under QK, changed 'two' to 'four' anesthesia assistants at one time.

04/15/2023 Updated policy template language due to North Carolina Health Choice Program's move to Medicaid; policy posted 4/15/2023 with effective date of 2023-04-01.

03/14/2022 Removed Attachment B: Billing Guidelines for Anesthesia Services with and without Medical Direction for revisions (amended date not changed).

01/01/2022 Attachment D removed (referenced in revision history).

Amended Date: August 15, 2023 appears throughout doc indicating updates to billing rules and examples.

No material clinical/coverage changes reported in this brief (has_material_change=false).

5Covered anesthesia types defined

Coverage Summary

This policy defines North Carolina Medicaid coverage, limitations, billing, and prior approval requirements for anesthesia services including general anesthesia, regional anesthesia, monitored anesthesia care (MAC), pain management procedures (e.g., peripheral nerve and epidural blocks), and local anesthesia. It specifies that anesthesia services include preanesthesia, intraoperative, and postanesthesia components and that time-based billing applies when a qualified anesthesia provider is in continuous personal attendance. The policy consolidates coverage rules, qualifying circumstances, provider eligibility, documentation requirements, and claim submission rules applicable to NC Medicaid.

Providers must follow prior approval processes when the underlying surgical procedure requires prior approval; the surgeon is responsible for obtaining prior approval and providers must submit prior approval requests and supporting health records to the DHHS Utilization Review Contractor. Medical record documentation must support services rendered, including the pre-anesthetic exam, beginning and end times of anesthesia, monitoring, postoperative notes, and evidence of medical direction.

Key thresholds and quick facts

Anesthesia for Extreme AgeReport for beneficiaries under 1 year and over 70 years of age

Obstetric anesthesia maxMaximum 180 time units (minutes) per date of service for listed obstetric anesthesia procedures; units billed exceeding 180 will be cut back unless supported by medical records

Provider supervision limit (AA/Anesthesiologist assistants)An anesthesiologist may supervise no more than four anesthesiologist assistants at one time

Provider supervision concurrent limit (medical direction QK)Medical direction by an anesthesiologist may be for up to 4 concurrent anesthesia procedures (QK); more than 4 uses AD

01996 frequencyOnly one charge of code 01996 allowed per day (includes related services that day)

Payment split when medically directedWhen medically directing a CRNA or AA, payment is calculated at 50% of the physician maximum allowed amount for both physician and CRNA/AA

Anesthesiologist supervision payment rule (>4 cases)If supervising >4 concurrent cases, anesthesiologist reimbursed 45 base units per procedure and may bill one-time 15-minute block if documented

Medical-Necessity & Coverage Criteria

General Coverage Criteria

Covered when ALL of the following are met:

Service is medically necessary
Procedure/product/service is individualized, specific, and consistent with symptoms or confirmed diagnosis and not in excess of beneficiary's needs
Service can be safely furnished and no equally effective, more conservative, or less costly treatment is available statewide
Service is not primarily for convenience of beneficiary, caretaker, or provider

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Coding and Modifiers

Qualifying CPT Codes for 99140CPTCovered

00100	Anesthesia for procedures on salivary glands, tonsils, adenoids
00102	Anesthesia for procedures on salivary glands, tonsils, adenoids; younger than 1 year
00300	Anesthesia for procedures on heart

Qualifying CPT Codes for 99116 or 99135CPTCovered

99116	Anesthesia complicated by utilization of total body hypothermia (List separately in addition to code for primary anesthesia procedure)
99135	Qualified anesthesiologist or other physician medical direction of two, three, or four concurrent anesthesia procedures (per 15 minutes)

Anesthesia CPT / qualifying procedure codes mentionedCPT

00400	Anesthesia for procedures on integumentary system of head, face, and scalp
00530	Anesthesia for procedures involving lower abdominal, perineal, and buttock
00630	Anesthesia for procedures on lower extremity
00740	Anesthesia for procedures on lower intestinal tract
00840	Anesthesia for colorectal procedures
00902	Anesthesia for cesarean delivery
01220	Anesthesia for procedures involving ribs, sternum
01400	Anesthesia for procedures on upper abdomen
01620	Anesthesia for procedures on the lower abdomen, perineum
01916	Anesthesia for diagnostic/therapeutic nerve blocks and injections (regional)

Dental sedation codesmixed

00170	Anesthesia for procedures involving the jaw
Dental - 41899	Unlisted procedure, dentoalveolar
D9220	Deep sedation/general anesthesia - provider dental code (HCPCS/Dental)
99141	Moderate sedation service (no longer commonly used for anesthesia billing; see policy 1L-2)

Modifiers required / describedModifier

AA	Anesthesia service performed personally by anesthesiologist
QK	Medical direction of two, three, or four concurrent anesthesia procedures
QS	Monitored anesthesia care service
AD	Medical supervision by a physician: more than four concurrent anesthesia procedures
TC	Technical component

Revenue codesRevenue

0960	Anesthesia
017X	Anesthesia, general (facility-specific)

ICD-10 diagnosis referencesICD-10

Z99.8	Dependence on other enabling machines and devices
G80.0	Spastic quadriplegic cerebral palsy (examples of conditions that may affect anesthesia decision-making)
O82	Encounter for cesarean delivery

Provider Actions & Billing Rules

Prior Authorization

Prior approval responsibility

When a surgical procedure requires prior approval, the surgeon is responsible for obtaining the prior approval. Submit the prior approval request and all supporting health records to the DHHS Utilization Review Contractor as required.

Documentation Required

Medical record documentation requirements

Maintain medical record documentation that supports services rendered, including the pre-anesthetic examination and evaluation, beginning and end times of anesthesia, monitoring of the beneficiary's vital signs, any postoperative anesthesia notes, codes reported, and evidence of medical direction. Records must be provided upon request for review.

Background & Definitions

Anesthesiology services consist of three core components: preanesthesia (preanesthetic evaluation and prescription of an anesthetic plan), intraoperative anesthesia care (administration and monitoring of anesthetic agents, intraoperative laboratory interpretation, treatment of adverse reactions, and administration of IV fluids/blood), and postanesthesia care (immediate postoperative monitoring and postoperative visits when applicable).

Time-based billing requires continuous actual physical presence (personal attendance) with the patient by an anesthesiology physician, resident, CRNA (per 21 NCAC 36.0226), or an anesthesiologist assistant supervised by an anesthesiologist; time starts when the provider begins preparing the patient for anesthesia care in the operating room or equivalent area and ends when the provider is no longer in personal attendance. The policy consolidates NC Medicaid coverage rules and billing guidance — including which monitoring and procedures are included in the anesthesia global package and which services must be billed separately (with modifier 59) — and provides claims-related instructions and modifier requirements in Attachment A.

Monitored Anesthesia Care (MAC): intra-operative monitoring provided in anticipation of possible need for general anesthesia or to address adverse physiological reactions; MAC requires continuous personal attendance and is billed with the QS modifier in addition to the appropriate anesthesia specialty modifier.

Certified Registered Nurse Anesthetist (CRNA): an advanced practice provider credentialed to provide anesthesia services; CRNA services are billed with the appropriate CRNA modifier (QX when medically directed, QZ when not medically directed) and follow scope and billing instructions described in the policy and Attachment A.

Anesthesiologist Assistant (AA): a clinician who works under the direction of an anesthesiologist; AAs require direct supervision, are reimbursed at 50% of the physician fee, and the supervising anesthesiologist may supervise up to four anesthesiologist assistants at one time as specified in provider qualification rules.

Revision History

2003-10-01effective_date

Original effective date of the policy established.

2010-06-01revision

Multiple Attachment A and payment/modifier clarifications and technical edits documented in revision history.

2012-03-01revision

Technical changes to merge Medicaid and NCHC coverage into one policy.

Policy Summary

PayerAlliance Health (LME/MCO)

PolicyAnesthesia Services

Policy CodePolicy 1L-1

Change TypeAmendment (08/15/2023)

Effective DateOct 1, 2003

Next Review Date

Key ActionWhen prior approval is required, the surgeon must obtain it and providers must maintain and provide documentation supporting anesthesia services on request.

SourceLink

On This Page

Time-Based Presence Requirement

Anesthesia time is covered when ALL of the following are met:

Continuous actual physical presence with the patient by anesthesiology physician, resident, CRNA (per 21 NCAC 36.0226), or anesthesiologist assistant supervised by an anesthesiologist
Time starts when provider begins to prepare the patient for anesthesia care in operating room or equivalent area
Time ends when provider is no longer in personal attendance and patient may be safely placed under postoperative supervision
Provider must be in constant attendance during the time billed

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Global Package Inclusion

Anesthesia global package includes ALL of the following unless billed separately with modifier 59:

Usual preoperative and postoperative visits
Anesthesia services during the procedure
Administration of intravenous fluids including blood and/or blood products
Intra-operative laboratory evaluations
Usual monitoring services (ECG, temperature, blood pressure, pulse oximetry, capnography, infrared end-tidal gas analysis, mass spectrography, bispectral EEG, transcranial Doppler) and their interpretation

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Services Not Included in Global Package (bill 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, peripheral nerve blockade)
Ultrasound-guided central venous access and assisted peripheral nerve blockade
Transesophageal echocardiography (TEE) monitoring and interpretation

Covered Types of Anesthesia

Covered when provided in accordance with general criteria and time-based presence:

General anesthesia: continuous presence required; includes preanesthetic exam, prescription, intraoperative monitoring, treatment of adverse reactions, fluids/blood administration, postoperative care
Regional anesthesia: continuous presence required; includes neuraxial, plexus, or peripheral nerve techniques and need to convert to general if necessary
Monitored Anesthesia Care (MAC): continuous presence required; intraoperative monitoring anticipating need for general anesthesia or adverse event
Pain management: peripheral nerve blocks, plexus blocks, epidural and caudal blocks for postoperative or intractable pain are covered
Local anesthesia: included in procedure fee when administered by operating physician (no separate reimbursement)
Anesthesia for oral procedures: refer to dental services policy #4A

Not Covered

Not covered when ANY of the following apply:

Beneficiary does not meet eligibility requirements in Section 2.0
Beneficiary does not meet criteria listed in Section 3.0
Procedure duplicates another provider's procedure/product/service
Procedure/product/service is experimental, investigational, or part of a clinical trial
Patient-controlled anesthesia (explicitly not covered)

Billing Rule

Global package and modifier 59

Anesthesia global package includes usual pre/postoperative visits, anesthesia during the procedure, IV fluids/blood administration, intra-operative labs, and routine monitoring; these services are not reimbursed separately unless unrelated and billed with modifier 59. Specific monitoring and insertions listed as not included in the global package must be billed separately with modifier 59.

Billing Rule

Epidural catheter daily follow-up limit

Only one follow-up code (daily hospital management of continuous epidural or subarachnoid drug administration after catheter insertion) is covered per day; that code includes all related services performed that day (visit, removal/adjustment, dose calculation, administration).

Billing Rule

Multiple procedures same date

When multiple surgical procedures occur on the same date, reimbursement is based on the base unit of the procedure with the highest base unit and time units based on the actual anesthesia time for the combined procedures. Medical records need not be submitted routinely but must be provided upon request.

Billing Rule

Labor/delivery/sterilization billing

Combinations of labor, delivery, or sterilization under general or epidural anesthesia are covered; sterilization will have cutback pricing when performed with delivery. If sterilization is performed after delivery on the same day in a return to the room/OR, report CPT 00851 separately and include total time units. Use ICD-10 code Z30.2 and modifier FP for sterilization billing per Attachment A guidance.

00851

Documentation Required

Consultation documentation

Consultations must be requested by the attending physician or other appropriate source and the need documented in the beneficiary's medical record. The consultant's opinion and any ordered or performed services must be documented and communicated by written report. Routine preoperative visits are not consultations.

Billing Rule

Anesthesiologist medical direction billing criteria

To bill for medical direction, the anesthesiologist must perform the pre-anesthesia evaluation and exam, prescribe the anesthesia, participate in induction and emergence, ensure qualified personnel perform parts not personally performed, monitor frequently, remain physically present and available in the operating suite, and provide post-anesthesia care.

Documentation Required

Provider eligibility and billing scope

Providers must meet Medicaid participation qualifications, have a current signed DHHS Provider Administrative Participation Agreement, and bill only for procedures, products, and services within the scope of their clinical practice as defined by their licensing entity.

Billing Rule

Claim types and billing guides

Use the appropriate claim form: Professional CMS-1500/837P for professional claims, Institutional UB-04/837I for facility claims, and Dental ADA/837D for dental; institutional claims must follow National Uniform Billing Guidelines and all claims must comply with National Coding Guidelines per Attachment A.

Billing Rule

Append required modifier to anesthesia CPT code

Append one appropriate anesthesia modifier (AA, QY, QK, AD, QZ, QX) to the anesthesia CPT code each time anesthesia is billed. MAC requires QS plus the appropriate AA/QK/QY or QX/QZ. Use modifier 59 for unrelated procedures with documentation and FP with sterilization (with ICD-10 Z30.2).

Billing Rule

Report anesthesia time units

Report anesthesia time in minutes as 1 minute = 1 unit in Item 24G of the CMS-1500 claim form. Time units are not recognized for codes 01967 and 01996 (flat rate applies) and certain neuraxial labor analgesia/anesthesia; those are allowed as a flat unit per occurrence.

01967
01996

Billing Rule

Limit on obstetric anesthesia units

There is a maximum of 180 time units (minutes) per date of service for specified obstetric anesthesia procedures (e.g., 01960, 01961, 01967, cesarean/urgent hysterectomy related codes). Units billed exceeding 180 will be cut back to 180 unless an adjustment with supporting medical records is submitted for consideration.

Billing Rule

Epidural management billing frequency

Only one charge of code 01996 (daily hospital management of epidural or subarachnoid continuous drug administration) is allowed per day; it includes all related services performed that day, does not require anesthesia modifiers, and may be billed by all physician specialties.

01996

Billing Rule

CRNA/AA billing and modifier specifics when employed by hospital

When a CRNA or anesthesiologist assistant is employed by a hospital or facility, the professional charges are billed on the hospital's CMS-1500 with the hospital's billing provider number in block 33; append QX for CRNA professional charges on the hospital claim. Facility charges are billed on UB-04 with 37X revenue codes. Anesthesiologist performing medical direction appends QY or QK.

Billing Rule

CRNA/AA billing when employed by anesthesiologist

When CRNA or anesthesiologist assistant services are provided and the CRNA/AA is employed by the anesthesiologist, the anesthesiologist bills medical direction with QK or QY on the physician claim; the CRNA/AA bills separately on a CMS-1500 with QX appended for CRNA (or no modifier for an anesthesiologist assistant on their separate claim per policy). Follow block 33 provider number instructions.

Billing Rule

Anesthesiologist supervision payment rule (>4 cases)

If an anesthesiologist supervises more than four concurrent anesthesia procedures, bill with the AD modifier. The supervising anesthesiologist is reimbursed 45 base units for every procedure being supervised and may bill a one-time 15-minute block if presence at induction is documented. The supervisory limit is four anesthesiologist assistants at one time.

Documentation Required

Documentation for teaching anesthesiologist

When a teaching anesthesiologist is involved with residents, documentation must show the teaching anesthesiologist was present during all critical portions to receive an unreduced fee; documentation must be available for review to support billing when involved with residents or concurrent cases.

Billing Rule

Calculation of payment

Payment is calculated using base units plus time units multiplied by the allowed amount. When medically directing a CRNA or anesthesiologist assistant, apply 50% of the physician maximum allowed amount for both physician and CRNA/AA as specified; anesthesiologist assistants are reimbursed at 50% of physician maximum allowed amount (no modifier).

Billing Rule

Pain management injections billing

Pain management injection procedures are not reimbursable by time. Submit the appropriate CPT procedure code and units corresponding to the number of services performed. If the injection or catheter insertion is performed primarily for postoperative pain, append modifier 59 to indicate the service is separately reportable from the anesthesia global service.