Reimbursement Policy Professional Anesthesia Services
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Governs reimbursement rules for professional anesthesia services for Amerigroup covered members (Georgia plans listed), including billing units, modifiers, reimbursable and nonreimbursable situations, and related coding guidance.
No material clinical or coverage changes in this revision.
Anesthesia Reimbursement Criteria
Anesthesia reimbursement criteria
Reimbursement is allowed when services are rendered by professional anesthesia providers for covered members and all billing, documentation, modifier, and state/CMS requirements are met.
ALL of the following
- Providers must report anesthesia services in minutes; claims submitted with an indicator other than minutes may not be processed or eligible for reimbursement.
- Start and stop times must be documented in the member's medical record.
- Anesthesia time starts with preparation of the member for administration of anesthesia and stops when the anesthesia provider is no longer in personal and continuous attendance.
- Health plan rounds time units to the nearest whole number.
ALL of the following
- When multiple anesthesia procedures occur, reimbursement is based on the anesthesia procedure with the highest base unit value plus the overall anesthesia time for all procedures.
- Reimbursement allowance is determined by the reimbursement formula and conversion factor in accordance with state guidelines.
ALL of the following
- Appropriate anesthesia modifiers must be appended; modifier identifying who performed the service must be the primary modifier.
Modifier payment outcomes
- Modifier AA — reimbursed at 100% of applicable fee schedule or contracted/negotiated rate.
- Modifier QZ — CRNA without medical direction — reimbursed at 100% of applicable fee schedule or contracted/negotiated amount.
- Modifier QK, QX, QY — medical direction/qualified nonphysician scenarios — reimbursed at 50% of the applicable fee schedule or contracted/negotiated amount.
- Modifier AD — medical supervision for more than four concurrent procedures — reimbursement not allowed.
- Modifier 23 substantiates anesthesia when a procedure normally done without anesthesia requires it and is reimbursed at 100% of the procedure; Modifier 47 is not appropriate for anesthesia reimbursement (see exclusions).
Special circumstances and qualifying additions
- Obstetrical neuraxial epidural anesthesia — reimbursed at a flat rate regardless of minutes when provided in conjunction with labor and delivery by the delivering physician or a qualified provider other than the delivering physician; rate based on time physically present with the member.
- Qualifier 99100 — allows one (1.0) additional base unit for patients younger than one year or older than 70 years, or for dental anesthesia in children up to 21 when medically necessary.
- Qualifier 99140 — allows two (2.0) additional base units for anesthesia complicated by emergency conditions.
- Patient status modifiers P3/P4/P5 provide additional one-time units as specified by coding guidance.
Separately reimbursable services (no time reporting)
- Swan-Ganz catheter insertion — reimbursable per fee schedule or contracted/negotiated rate with no time reporting.
- Central venous pressure line insertion — reimbursable per fee schedule or contracted/negotiated rate with no time reporting.
- Intra-arterial lines — reimbursable per fee schedule or contracted/negotiated rate with no time reporting.
- Emergency intubation — reimbursable only when provided in conjunction with the anesthesia procedure; reimbursed per fee schedule or contracted/negotiated rate with no time reporting.
- Critical care visits — reimbursable per fee schedule or contracted/negotiated rate with no time reporting.
- Transesophageal echocardiography — reimbursable per fee schedule or contracted/negotiated rate with no time reporting.
ALL of the following
- Anesthesia consultations on the same date as surgery or the day prior when part of the preoperative assessment.
- Anesthesia services for non-covered procedures, including services considered not medically necessary, experimental, and/or investigational.
- Anesthesia services provided by the provider performing the basic procedure (except delivering physician providing continuous epidural analgesia for obstetrical anesthesia).
- Local anesthesia incidental to the surgical procedure.
- Standby anesthesia services.
Report anesthesia services in minutes with documented start and stop times; services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis and member's state of residence. Noncompliant coding may lead to claim rejection, denial, or recovery.
Modifiers, Codes, and Time Reporting
| AA | Anesthesia services personally performed by the anesthesiologist; reimbursed at 100% of applicable fee schedule or contracted/negotiated rate. |
| AD | Medical supervision by a physician: more than four (4) concurrent anesthesia procedures; reimbursement is not allowed. |
| QK | Medical direction of two, three, or four concurrent anesthesia procedures involving qualified individuals; reimbursed at 50% of allowance (50% of applicable fee schedule or contracted/negotiated amount). |
| QX | Qualified nonphysician anesthetist with medical direction by a physician; reimbursed at 50% of the applicable fee schedule or contracted/negotiated amount. |
| QY | Anesthesiologist medically directs one CRNA; reimbursed at 50% of the applicable fee schedule or contracted/negotiated amount. |
| QZ | CRNA without medical direction by a physician; reimbursed at 100% of the applicable fee schedule or contracted/negotiated amount. |
| P3 | Patient with severe systemic disease; allows additional reimbursement of one-time unit. |
| P4 | Patient with severe systemic disease that is a constant threat to life; allows additional reimbursement of two-time units. |
| P5 | Moribund patient not expected to survive without operation; allows additional reimbursement of three-time units. |
| 99100 | Allows one (1.0) additional base unit for anesthesia services for a member younger than one year old or older than 70 years old, or when medically necessary for children up to 21 years old who need anesthesia for dental procedures. |
Claim Submission, Documentation, and Authorization
Claim submission, time reporting, and documentation requirements
Report anesthesia services in minutes on all claims and document start and stop times in the member's medical record. Anesthesia time begins with preparation for administration and ends when the anesthesia provider is no longer in personal and continuous attendance; the health plan rounds time units to the nearest whole number. Use industry-standard, compliant CPT/HCPCS/revenue codes that are fully supported in the medical record; claims submitted with an indicator other than minutes may not be processed or may not be eligible for reimbursement.
- Report minutes (time units) — do not submit alternate time indicators.
- Document start and stop times in the medical record.
- Time begins with preparation and ends when provider is no longer in personal and continuous attendance.
- Time units are rounded to the nearest whole number.
- Bill with appropriate CPT, HCPCS, and/or revenue codes fully supported by documentation.
Prior authorization and medical necessity requirements
Obtain and ensure services meet applicable authorization and medical necessity requirements for the procedure, diagnosis, and member's state of residence. Failure to follow appropriate coding, billing, or authorization requirements may result in claim rejection, denial, recoupment, or adjusted reimbursement.
- Verify any required prior authorization per member benefit and state/CMS mandates before providing services.
- Ensure documentation and coding support medical necessity for the billed services.
- Noncompliance may lead to rejection, denial, recovery/recoupment, or payment adjustment.
Key Terms and Definitions
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