CurrentAlliance HealthPolicy 1L-1

Anesthesia Services

NC Medicaid clinical coverage policy defining coverage, limitations, prior approval, billing, provider qualifications, documentation, and qualifying circumstances for anesthesia services (general, regional, monitored anesthesia care, pain management, local anesthesia, and related provisions). This is Part 1 of 2 and includes policy statements, definitions, coverage/noncoverage, prior approval and billing guidance, and attachments for claims-related information.

Policy Summary

PayerAlliance Health

PolicyAnesthesia Services

Policy CodePolicy 1L-1

Change TypeRevision (08/15/2023)

Effective DateOct 1, 2003

Next Review DateN/A

Key ActionWhen a surgical procedure requires prior approval, the surgeon must obtain it and submit the prior approval request and supporting health records to the DHHS Utilization Review Contractor.

SourceLink

POLICY UPDATE CHANGES

08/15/2023 Section 6.1 revised to change 'two' to 'four' anesthesia assistants at one time; Attachment A Section D modifiers updated similarly.

04/15/2023 Policy template language updated due to North Carolina Health Choice Program's move to Medicaid with policy posted 4/15/2023 and effective date 4/01/2023.

03/14/2022 Attachment B revised: billing guidelines removed for anesthesia services with and without medical direction; amended date not changed.

01/01/2022 Attachment D reference removed.

Amended Date: August 15, 2023 appears throughout as amendment date for billing and employment sections.

5Types of anesthesia covered

8Qualifying circumstances listed

180Obstetric max minutes/day

MultipleReferenced CPT/Modifier Codes

50%Reimbursement when medically directed

Coverage Summary

NC Medicaid Clinical Coverage Policy 1L-1 (Anesthesia Services) defines coverage, limitations, prior approval, billing, provider qualifications, documentation, and qualifying circumstances for anesthesia services. Scope includes general, regional, and monitored anesthesia care (MAC), pain management, local anesthesia, and related provisions. Policy effective date: October 1, 2003; last review/amendment: August 15, 2023. This output represents Part 1 of 2 of the policy.

Surface thresholds and quick facts

Obstetric anesthesia maximum units per date of service180 units (minutes) per date of service; units billed exceeding 180 will be cut back unless medical records justify additional units

Reimbursement when medically directing CRNA/AA50% of the physician maximum allowed amount (medical direction payment rate)

Base units reimbursed when supervising >4 CRNAs45 base units per procedure supervised (physician allowable) with possible one-time 15‑minute induction block if documented

Anesthesiologist assistant reimbursementReimbursed at 50% of the physician fee (calculated as (Base units + time) x 50%)

Counts / quick factsTypes of anesthesia covered: 5; Qualifying circumstances listed: 8; Obstetric max minutes per day: 180

Medical-Necessity & Coverage Criteria

General Coverage Criteria

Covered when ALL of the following are met:

ALL of the following

Anesthesia services are furnished by a licensed anesthesiologist, certified registered nurse anesthetist (CRNA), or other provider permitted by state law and the payer to provide anesthesia services.
The anesthesia is medically necessary for the performance of a covered procedure or to control pain or physiologic state such that the procedure can be performed safely.
The type and extent of anesthesia provided are appropriate to the procedure, the beneficiary’s medical condition, and documented comorbidities or complicating factors.
The anesthesia record documents preoperative evaluation, monitoring during the procedure, agents and dosages used, intraoperative events, and postoperative disposition and recovery instructions.

Coding & Billing Rules

Dental sedation codes referencedHCPCS|CPT|mixedCovered

D9220	Dental code referenced as equivalent to D9221 per policy
D9221	Dental code referenced

Qualifying CPT Codes for 99140CPTCovered

00210	Qualifying procedure for 99140
00212	Qualifying procedure for 99140
00214	Qualifying procedure for 99140
00215	Qualifying procedure for 99140
00400	Qualifying procedure for 99140 (marked with *)
00540	Qualifying procedure for 99140
00541	Qualifying procedure for 99140
00560	Qualifying procedure for 99140
00562	Qualifying procedure for 99140
00563	Qualifying procedure for 99140

1–10 of 19

1/2

Qualifying CPT Codes for 99116 or 99135CPTCovered

00210	Qualifying procedure for 99116/99135
00215	Qualifying procedure for 99116/99135
00540	Qualifying procedure for 99116/99135
00541	Qualifying procedure for 99116/99135
00560	Qualifying procedure for 99116/99135
00562	Qualifying procedure for 99116/99135
00563	Qualifying procedure for 99116/99135
00770	Qualifying procedure for 99116/99135
00880	Qualifying procedure for 99116/99135
00882	Qualifying procedure for 99116/99135

1–10 of 12

1/2

Anesthesia CPT codes (general guidance)CPTCovered

00851

Anesthesia CPT code referenced for sterilization when reported separately after return to OR/delivery room

Qualifying CPT Codes for 99140CPT

00210
00212
00214
00215
00400
00540
00541
00560
00562
00563

1–10 of 19

1/2

Qualifying CPT Codes for 99116 or 99135CPT

00210
00215
00540
00541
00560
00562
00563
00770
00880
00882

1–10 of 12

1/2

Anesthesia CPT Codes referenced for sterilization and obstetricCPT

01967	Neuraxial labor analgesia/anesthesia for planned vaginal delivery
01968	Obstetric add-on code
01969	Obstetric add-on code
01960
01961
00840
00851
00921

Other specific CPTs called outCPT

01996

Daily hospital management of epidural or subarachnoid continuous drug administration

Dental codesADA

D9220
D9221

ModifiersModifier

AA	Anesthesia services performed personally by anesthesiologist
QY	Medical direction of 1 CRNA/AA by anesthesiologist
QK	Medical direction of 2-4 concurrent anesthesia procedures
AD	Medical supervision by a physician: more than 4 concurrent anesthesia procedures
QZ	CRNA service without medical direction
QX	CRNA service with medical direction by a physician
QS	Monitored Anesthesia Care service indicator (used in combination)
59	Distinct procedural service
FP	Sterilization procedure modifier (for anesthesia codes used for sterilization with diagnosis Z30.2)

ICD-10 Diagnosis for SterilizationICD-10

Z30.2

Encounter for sterilization

Modifier and Billing Requirements

Providers must append specific modifiers and follow billing workflows depending on provider type, service, and supervision. Separate nodes preserve modifier/billing, scenarios, services without medical direction, and time rules.

Append modifier: One of the following modifiers must be appended to the anesthesia CPT code each time anesthesia is billed by anesthesiologists or a CRNA: AA, QY, QK, AD, QZ, QX.
MAC modifier use: When Monitored Anesthesia Care (MAC) is billed, anesthesiologists must append AA, QK, or QY in addition to QS; CRNAs must append QX or QZ in addition to QS.
Modifier 59: Use modifier 59 to indicate when a procedure is unrelated to the administration of anesthesia and should be considered for separate reimbursement.

Provider Actions & Operational Requirements

Prior Authorization

Surgeon responsible for prior approval

When a surgical procedure requires prior approval, the surgeon (not the anesthesia provider) is responsible for obtaining prior approval and submitting the prior approval request and supporting health records to the DHHS Utilization Review Contractor.

Documentation Required

Medical record documentation requirements

Maintain complete medical record documentation to support services billed. Documentation must include the pre-anesthetic examination and evaluation, the beginning and end times of anesthesia, monitoring of the beneficiary's vital signs, any postoperative anesthesia notes, and evidence indicating medical direction when billed. Provide records upon request to substantiate billed codes and services.

Pre-anesthetic examination and evaluation

Provider Qualifications & Reimbursement Calculation

Provider Qualifications (limits)

Provider Qualifications (limits):

CRNA qualifications reference: Refer to 21 NCAC 36.0226 for CRNA qualifications.
Anesthesiologist assistant supervision: The anesthesiologist assistant must work under the direction of an anesthesiologist (42 CFR §410.69).
Supervision limit change: An anesthesiologist may supervise no more than four anesthesiologist assistants at one time (Section 6.1 revision 08/15/2023 changed 'two' to 'four').

When a teaching anesthesiologist supervises residents, payment is allowed without reduction if the teaching anesthesiologist is involved in a single procedure with one resident or in two concurrent anesthesia cases with residents (effective for services on or after January 1, 2010). Documentation in the medical record must confirm the teaching anesthesiologist's presence during all critical portions to support payment; mere presence only during pre/post-op visits is insufficient.

Documentation Requirements

Providers must comply with all applicable agreements, federal, state, and local laws and regulations including HIPAA and record retention requirements, and must follow NC Medicaid clinical coverage policies, guidelines, provider manuals, implementation updates, and bulletins. Providers must also meet Medicaid participation requirements (including a current signed DHHS Provider Administrative Participation Agreement) and bill only within the scope of their licensed practice.

Background

Anesthesiology includes preanesthesia, intraoperative anesthesia, and postanesthesia care across general, regional, and monitored anesthesia care; services include monitoring, interpretation of intraoperative labs, administration of intravenous fluids and blood products, and postoperative visits. Time-based anesthesia services require the continuous actual physical presence of a qualified anesthesia provider (anesthesiologist, resident, CRNA, or anesthesiologist assistant supervised by an anesthesiologist), with time starting when preparation for anesthesia care begins in the operating room or equivalent area and ending when the provider is no longer in personal attendance.

Key definitions

Global packageThe bundled anesthesia services including usual preoperative and postoperative visits, anesthesia during the procedure, administration of IV fluids including blood/products, intra-operative labs, and routine monitoring and interpretation; certain monitoring procedures are excluded and billed separately

MACMonitored Anesthesia Care; when billed it requires QS plus the appropriate provider modifier

Base unitsProcedure-assigned units according to procedure complexity used together with time units to calculate anesthesia reimbursement

Labor, Delivery & Sterilization Specific Rules

Labor, Delivery, Sterilization

Coverage rules for combined procedures and specific billing rules for labor, delivery, and sterilization:

Combinations covered with cutback: Combinations of labor, delivery, or sterilization under general or epidural anesthesia are covered for the same patient encounter; sterilization will have cutback pricing applied and both services will be allowed.
Return to OR sterilization separate code: If beneficiary is brought back after labor/delivery or cesarean to perform sterilization (even same day), report anesthesia CPT code 00851 as a separate procedure and include total time units.
FP modifier and Z30.2: CPT anesthesia codes for sterilization must be billed with ICD-10-CM diagnosis code Z30.2 and modifier FP appended to the CPT code.

Revision History

2003-10-01original_effective

Original effective date of the Anesthesia Services clinical coverage policy (1L-1) established.

2009-07-01revision

Policy sections revised throughout as part of initial promulgation of current coverage and technical updates.

2010-06-01revision

Attachment A Section D and other attachment clarifications updated; clarified AD modifier description for supervision of more than four concurrent cases and other modifier/payment instructions.

Policy Summary

PayerAlliance Health

PolicyAnesthesia Services

Policy CodePolicy 1L-1

Change TypeRevision (08/15/2023)

Effective DateOct 1, 2003

Next Review DateN/A

Key ActionWhen a surgical procedure requires prior approval, the surgeon must obtain it and submit the prior approval request and supporting health records to the DHHS Utilization Review Contractor.

SourceLink

On This Page

Time Factors

Anesthesia time is covered according to the following requirements:

ALL of the following

Anesthesia time begins when the anesthesiologist or CRNA begins continuous pre-operative evaluation and preparation of the patient in anticipation of induction of anesthesia (e.g., placement of invasive monitoring, airway evaluation) and ends when the anesthesia provider is no longer immediately available to provide anesthesia care and monitoring because the patient has been transferred to the recovery area and the immediate postoperative anesthesia care is complete.
Start and stop times must be documented in the anesthesia record.
Units are calculated using time-based anesthesia CPT guidelines; the documented anesthesia start and stop times determine billable duration.
Round time per CPT guidance and payer billing rules.
Time spent by the anesthesiologist providing medical direction for qualified CRNAs is reported by the anesthesiologist; CRNAs report their own time when billing independently per provider eligibility rules.

Global Package Included Services

Anesthesia global package includes the following when performed as part of the operative episode:

ALL of the following

Pre-anesthetic evaluation and preparation of the patient.
Administration of anesthesia and monitoring during the procedure.
Post-anesthesia recovery and discharge preparation related to the anesthesia (immediate postoperative anesthesia management).
Management of routine postoperative nausea and vomiting related to anesthesia.

Services Not Included in Global Package

The following services are NOT included in the anesthesia global package (any may be billed separately if performed and appropriately documented):

ANY of the following

Independent evaluation and management (E/M) services not related to preoperative or immediate postoperative anesthesia management (e.g., separate problem-focused visits).
Anesthesia consultations billed separately when documentation supports a distinct consultation service (see Anesthesia Consultations group).
Postoperative pain management services that are distinct, ongoing, or not part of the routine immediate postoperative care (e.g., prolonged pain service).
Services specifically excluded by payer rules such as stand-by anesthesia when not medically necessary.

Types of Anesthesia Covered

Covered types of anesthesia (at least ONE of the following):

ANY of the following

General anesthesia.
Regional anesthesia (including neuraxial blocks and peripheral nerve blocks).
Monitored Anesthesia Care (MAC) or deep sedation when warranted by patient condition or procedure.
Anesthesia for pain management procedures when medically necessary and documented.
Local anesthesia when provided by an eligible anesthesia provider and billed per payer rules.

Not Covered

Medicaid does NOT cover the following (any of):

ANY of the following

Patient-controlled anesthesia systems billed as separate anesthesia services when payer policy excludes them.
Intravenous sedation or moderate conscious sedation billed under the anesthesia global package when state/payer policy requires separate coverage under the Moderate (Conscious) Sedation policy (see policy 1L-2).
Standby anesthesia when no active anesthesia services are rendered and medical necessity is not documented.
Anesthesia services provided by unlicensed or otherwise ineligible providers.

Prior Approval Requirements

Prior approval and submission requirements:

ALL of the following

Surgeon responsibility: The operating surgeon must request prior approval when required by payer policy for the planned procedure; prior approval for the surgical/procedural service does not automatically approve separate anesthesia requests that are listed as requiring prior authorization.
Provider submission requirements: When prior approval is required for anesthesia services (per payer prior authorization rules), the anesthesia provider or facility must submit clinical justification, anticipated anesthesia type, estimated duration, relevant comorbidities, and supporting records (e.g., pre-anesthetic evaluation).

Anesthesiologist Medical Direction Billing Criteria

Anesthesiologist medical direction, supervision, and billing requirements (all must be met to bill medical direction):

ALL of the following

The anesthesiologist performs a pre-anesthetic exam and evaluation and prescribes the anesthesia plan.
The anesthesiologist personally participates in the most demanding parts of the anesthesia plan, including induction and emergence when applicable.
The anesthesiologist is immediately available throughout the procedure and remains physically present in the operating suite when required by payer rules; immediate availability must be documented.
If on-site availability is required by state or payer rules, documentation must support presence or immediate access.
The anesthesiologist provides direct supervision and monitors the performance of up to the allowed number of concurrent anesthesia practitioners as specified by payer rules (medical direction limits).
The anesthesiologist documents in the medical record the medical direction provided, including specific concurrent activities and time spent, and signs the anesthesia record.

Clarification of Simultaneous Activities during Medical Direction

Clarification of simultaneous activities during medical direction (when an anesthesiologist may engage in the following while directing concurrent anesthesia care):

ALL of the following

An anesthesiologist directing concurrent cases may perform activities such as pre-anesthesia evaluations, regional blocks, invasive line placement, or induction/emergence for one patient while another qualified anesthesia provider is providing anesthesia care, provided that immediate availability to intervene for each concurrently directed patient is maintained as required by payer rules.
The anesthesiologist may not perform activities that would prevent immediate availability to the concurrent patient(s); documentation must specify the simultaneous activities and how immediate availability is preserved.
When the anesthesiologist is providing medical direction to multiple CRNAs or other qualified providers, the specific permissible concurrent activities and the maximum number of concurrent cases must comply with state law and payer medical direction limits.

Multiple Procedures Same Date

Multiple procedures and billing on the same date of service:

ALL of the following

When multiple procedures are performed during the same anesthetic episode on the same date of service, anesthesia payment is based on the total anesthesia time for the combined procedures; document start and stop times and list all procedures performed.
If separate anesthesia episodes occur on the same date of service (distinct induction and emergence episodes separated by patient transfer or a clear break in anesthesia care), each episode may be reported separately with supporting documentation.
For multiple surgical procedures performed during the same anesthesia, appropriate modifiers and coding conventions must be used; follow payer coding guidance for multiple procedures same date.

E/M and Anesthesia Interaction

Interaction of Evaluation and Management (E/M) codes with anesthesia services:

ALL of the following

E/M services furnished by the anesthesia provider are included in the anesthesia global package when they are part of routine preoperative or immediate postoperative care and are not separately billable.
Separate E/M billing is allowed only when the E/M service is significant, separately identifiable, and fully documented as distinct from the anesthesia preoperative evaluation or routine postoperative management; use appropriate E/M and modifier guidance when billing separately.
Termination of surgery: time-based anesthesia units end at termination as defined in Time Factors; E/M services related to unrelated problems may be billed separately with documentation.

Anesthesia Consultations

Anesthesia consultations (may be billed separately when ALL of the following are met):

ALL of the following

A formal consultation is requested by the treating clinician and documented in the medical record as a consultation rather than routine preoperative evaluation.
The consultation involves evaluation and management beyond routine pre-anesthetic assessment and results in recommendations that affect the planned procedure or anesthesia management.
The consultation is documented with findings, medical decision making, and a written report; the anesthesiologist documents that a consultation was performed and signs the record.

Provider Eligibility to Bill

Provider eligibility and billing rules:

ALL of the following

Only providers authorized by state law and the payer (e.g., licensed physicians, board-certified anesthesiologists, CRNAs where applicable) may bill for anesthesia services; facilities must verify provider credentials and eligibility.
Providers must meet payer enrollment and credentialing requirements prior to billing for anesthesia services; payment may be denied if provider is not enrolled or credentialed per payer rules.
Billing must reflect who furnished the service and the appropriate provider identifier; incident-to billing rules do not override anesthesia-specific provider eligibility requirements.

Teaching Anesthesiologist / Resident Billing

Teaching anesthesiologist and resident billing rules (all must be met to bill for services involving residents):

ALL of the following

When a teaching anesthesiologist oversees a resident, billing must comply with payer policies regarding supervision, documentation of the extent of involvement, and state regulations governing resident supervision and billing.
If the teaching anesthesiologist participates personally in key portions of the care (e.g., pre-anesthetic evaluation, induction, emergence) and documents medical direction per anesthesiologist medical direction criteria, the anesthesiologist may bill for medical direction as allowed by payer rules.
If a resident furnishes the anesthesia service without required teaching anesthesiologist presence or documentation, the service may not be billable separately by the teaching anesthesiologist; documentation must clearly reflect who performed which components of care.

Medical direction modifiers: When an anesthesiologist provides medical direction, append QY or QK to the anesthesia CPT code; append QX to the CPT code billed on the CRNA claim.

Anesthesiologist assistant reimbursement note: Anesthesiologist assistants reimbursed at 50% of physician fee.

CRNA / Anesthesiologist / Anesthesiologist Assistant Billing Scenarios

CRNA Employed by Hospital or Facility: CRNA professional charges are billed on the hospital's professional claim (CMS-1500); append modifier QX to the CPT code; hospital billing provider number entered in block 33; CRNA attending number entered in attending area; facility charges billed on UB-04 with revenue codes in 37X range; anesthesiologist performing medical direction appends QY or QK.
CRNA Employed by an Anesthesiologist: Anesthesiologist bills medical direction appending QK or QY; physician group provider number in block 33; CRNA services billed on separate CMS-1500 with QX appended; CRNA provider number in attending area.
Anesthesiologist Assistant Employed by Hospital or Facility: Anesthesiologist assistant professional charges billed on hospital's professional claim (CMS-1500); hospital billing provider number in block 33; assistant attending number in attending area; facility charges billed on UB-04 with 37X revenue codes; anesthesiologist performing medical direction appends QY or QK.
Anesthesiologist Assistant Employed by Anesthesiologist: Anesthesiologist bills medical direction appending QK or QY; anesthesiologist assistant services billed on a separate CMS-1500 claim without a modifier (appending a modifier will cause the claim to deny).

Billing for Services Without Medical Direction

AA and QZ usage: AA modifier indicates services performed personally by anesthesiologist; if a CRNA performs service without medical direction, append QZ modifier to the anesthesia CPT code.
AD modifier and >4 cases: AD modifier indicates medical supervision provided to a CRNA (>4 concurrent cases); QZ must be appended by CRNA; anesthesiologist reimbursed 45 base units per procedure supervised and may bill a one-time 15-minute block if document presence at anesthetic induction.
Reduce billed time if not in attendance: If surgery delayed and anesthesia provider not in constant attendance, reduce time billed to reflect actual time spent with beneficiary.

Time Reporting and Units

Minutes-to-units: Providers must report time for all general and monitored anesthesia services as 1 minute = 1 unit.
Flat-rate exceptions: Time units are not recognized for anesthesia codes 01967 or 01996 and neuraxial labor analgesia/anesthesia for planned vaginal delivery; these have a flat rate of 1 unit per occurrence.
Obstetric max units: Maximum unit limitation of 180 units (minutes) per date of service for specified obstetric anesthesia procedures; units exceeding 180 will be cut back unless adjustment with medical records submitted for additional payment consideration.
01996 one per day: Only one charge of code 01996 is allowed per day; does not require anesthesia modifiers and may be billed by all physician specialties.

Pain Management and Epidural/Block Billing

Not reimbursable by time: Pain management procedures are not reimbursable by time; submit appropriate CPT codes with units corresponding to number of services rendered.
Postoperative pain blocks separate billing: If injection or insertion of block/continuous catheter is performed primarily for postoperative pain management, bill appropriate procedure code with modifier 59 to designate separately reportable service (not bundled with anesthesia global service).

Dental Anesthesia Billing

Dental billing rules: Physicians and CRNAs administering dental anesthesia bill anesthesia CPT procedure codes; enter anesthesia time in block 24G of CMS-1500 as '1 minute = 1 unit'.
Dental code mapping: If analgesia/anesthesia is rendered in the dental office, the dentist bills using ADA procedure codes; dental code mapping: D9220 = D9221.

Labor, Delivery, and Sterilization Billing Rules

FP modifier and Z30.2: CPT anesthesia codes for sterilization must be billed with ICD-10-CM diagnosis code Z30.2 and modifier FP appended to the CPT code.
Sterilization CPTs: CPT anesthesia procedure codes that may be used for sterilization: 00840, 00851, 00921.
Cutback pricing: Anesthesia reimbursement for sterilization billed with labor and delivery is cut back to a flat fee when billed in conjunction with labor and delivery; obstetric add-on codes 01968 and 01969 may be billed within 48 hours of 01967; when delivery immediately followed by sterilization, delivery paid at 100% calculated amount and sterilization flat fee cutback applies.
Attachment B examples: Attachment B provides detailed code/time rules and cutback pricing for combinations (examples include codes 01967, 01968, 01969, 01960, 01961, 00840, 00851, 00921).

Reimbursement Calculation

Anesthesiologists: If personally performed (AA): (Base units + time) x physician maximum allowed amount = physician payment; If medically directs CRNA/AA (QY): (Base units + time) x 50% of physician maximum allowed amount = physician payment; If medically supervises CRNA (AD for >4): physician allowable is 45 base units per procedure supervised and may bill a one-time 15-minute block with documentation.
CRNA: If CRNA not medically directed (QZ): (Base units + time) x CRNA maximum allowed amount = CRNA payment; If CRNA medically directed (QX): (Base units + time) x 50% of physician maximum allowed amount = CRNA payment.
Anesthesiologist Assistant reimbursement = (Base units + time) x 50% of physician maximum allowed amount (no modifier used).

Combinations of labor, delivery, and sterilization under general or epidural anesthesia are covered for the same patient encounter, but sterilization will have cutback pricing applied when billed with labor/delivery. If sterilization is performed after return to the delivery room or operating room (even same day), report anesthesia CPT code 00851 as a separate procedure and include total time units. For sterilization procedures, append ICD-10-CM diagnosis code Z30.2 and the sterilization modifier FP to the anesthesia CPT code; allowed CPT sterilization procedure codes include 00840, 00851, 00921.

Beginning and end times of anesthesia (time reported as minutes)

Monitoring of vital signs

Postoperative anesthesia notes

Documentation indicating medical direction when billed

Billing Rule

Global package and separate billing

The global anesthesia package includes routine preoperative/postoperative visits, intraoperative anesthesia, administration of IV fluids/blood, routine monitoring and interpretation. Services that are unrelated to the administration of anesthesia (for example invasive monitoring, nerve blocks for postoperative pain, TEE) are not included and must be billed separately with modifier 59 to indicate separate reimbursement.

Billing Rule

Epidural catheter follow-up limit

Only one follow-up code for daily hospital management of continuous epidural or subarachnoid drug administration after catheter insertion (01996) is covered per day; that code includes related services performed that day such as visit, catheter removal/adjustment, dose calculation, and administration.

Billing Rule

Multiple procedures same date reimbursement

When multiple surgical procedures occur on the same date, reimbursement is based on the base unit value of the procedure with the highest base units; time units are based on the actual anesthesia time for the combined procedures. Medical records are not required with the claim but must be provided upon request.

Billing Rule

Anesthesia stand-by billing

Anesthesia stand-by services are covered for high‑risk deliveries when the appropriate diagnosis code is used and no other anesthesia services are provided.

Billing Rule

E/M vs anesthesia

Critical care E/M and respiratory ventilator management E/M services may be billed separately when extended care beyond the immediate postoperative period is required; append modifier 25. If induction of anesthesia has begun, reimbursement is for the anesthesia CPT base units plus actual time.

Billing Rule

Append appropriate modifier to anesthesia CPT codes

Append the appropriate anesthesia and service modifiers to anesthesia CPT codes as required by provider role and service: AA, QY, QK, AD, QZ, QX, and QS for MAC. Use modifier 59 to indicate an unrelated procedure and modifier FP when billing anesthesia for sterilization with diagnosis code Z30.2. Incorrect modifier use on anesthesiologist assistant claims (for certain employment arrangements) may cause denial.

Billing Rule

Report anesthesia time as minutes

Report anesthesia time as minutes (1 minute = 1 unit) in block 24G of the CMS-1500 for general and monitored anesthesia services. Exceptions: time units are not recognized for neuraxial labor analgesia/anesthesia for planned vaginal delivery (01967) and for daily hospital management of epidural/subarachnoid continuous drug administration (01996); these codes use a flat 1 unit per occurrence.

Billing Rule

CRNA and Anesthesiologist billing/form entries

Follow the specified claim form and block 33 population rules depending on employment arrangement. CRNA and anesthesiologist professional charges are billed on CMS-1500; facility charges on UB-04 with 37X revenue codes. Enter the hospital or physician group billing provider number in block 33 as directed and place the attending/provider numbers in the attending area per scenario.

Documentation Required

Documentation of medical direction/supervision and teaching involvement

Document medical direction, supervision, and teaching involvement in the medical record. For medical direction billing, documentation must show performance of pre-anesthesia evaluation/exam, prescription of anesthesia, participation in induction and emergence, monitoring at frequent intervals, and availability in the operating suite. Teaching anesthesiologists must document presence during all critical portions to support payment.

Billing Rule

One daily 01996 allowed

Only one charge of CPT code 01996 is allowed per day; it includes all related services performed that day and does not require anesthesia modifiers. It may be billed by all physician specialties.

Denial Risk

Anesthesiologist Assistant modifier misuse causes denial

If an anesthesiologist assistant employed by an anesthesiologist appends a modifier to their separate CMS-1500 claim, the claim will deny; do not append a modifier for the anesthesiologist assistant in that employment scenario.

Sterilization CPTs and obstetric add-ons: CPT anesthesia procedure codes that may be used for sterilization: 00840, 00851, 00921; obstetric add-on codes 01968 and 01969 may be billed by same or different provider when billed within 48 hours of primary procedure code 01967.

Examples and Attachment B: Attachment B provides detailed code/time rules and cutback pricing for combinations (examples include codes 01967, 01968, 01969, 01960, 01961, 00840, 00851, 00921).

Epidural Catheter Follow-up Limitation and Qualifying Circumstances (additional units)

Epidural Catheter Follow-up Limitation

One follow-up per day: Only one follow-up code for daily hospital management of continuous epidural or subarachnoid drug administration performed after insertion of an epidural or subarachnoid catheter is covered per day; the code includes the visit, removal/adjustment of the catheter, dose calculation, and administration.

2012-03-01revision

All sections and attachments revised; technical changes to merge Medicaid and NCHC coverage into one policy.

2015-10-01revision

Policy template language updated and ICD-10 codes added to comply with federal implementation.

2019-03-15revision

Table of Contents and template language updated; notice added for beneficiaries enrolled in Prepaid Health Plans (PHP).

2019-12-20revision

Attachment A revised to add billing guidance and national uniform billing guidance language.

2022-03-14administrative_revision

Attachment B revised: billing guidelines for anesthesia services with and without medical direction were removed (amended date not changed).

2022-01-01administrative_revision

Attachment D reference removed from the policy attachments.

2023-04-15administrative_revision

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

2023-08-15material_revisionLatest

Section 6.1 and Attachment A Section D revised to change the anesthesiologist supervision limit from two to four anesthesiologist assistants at one time; modifiers updated accordingly (QK language changed to allow supervision of up to four).