CurrentAnthemPolicy C-09002

Anesthesia Services - Professional, Commercial Reimbursement Policy

Defines Anthem's reimbursement rules for professional anesthesia services (time reporting, modifiers, qualifying circumstances, included/excluded services, oral surgery rules, postoperative pain management) for commercial plans.

Policy Summary

PayerAnthem

PolicyAnesthesia Services - Professional, Commercial Reimbursement Policy

Policy CodePolicy C-09002

Change TypeNo material changes

Effective DateMar 11, 2026

Next Review DateN/A

Key ActionReport anesthesia time in one-minute increments and document start/stop times in the medical record to ensure correct units conversion and avoid claim denials.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1-mintime reporting granularity

15minutes per billing unit

150%bilateral reimbursement allowance

Not reimbursedfacility drug billing

5minimum base units (field avoidance)

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Anesthesia Coverage and Reimbursement Rules

General rules

General coverage and reporting rules

Reimbursement for anesthesia services follows the American Society of Anesthesiologists (ASA) anesthesia formula unless otherwise noted.

Services must be reported using anesthesia procedure codes and, when applicable, a physical status modifier and/or a servicing modifier.

Additional factors such as field avoidance and unusual positioning are considered in reimbursement determinations.

Time & modifiers

Time and modifier requirements

Report anesthesia time in one-minute increments; anesthesia time starts with preparation of the member for administration of anesthesia and ends when the anesthesia provider is no longer in personal attendance.

To calculate time units, divide the number of minutes reported by 15 and round to the nearest tenth.

Start and stop times must be documented in the medical record; claims submitted with an indicator other than minutes may be rejected or denied.

Append appropriate anesthesia modifiers to the procedure code; modifiers identifying who performed the anesthesia must be billed in the primary modifier field.

Claims submitted for anesthesiology services without the appropriate modifier will be denied; total reimbursement for physician and non-physician anesthesia providers combined will not exceed 100%.

Multiple procedures

When anesthesia services are provided for multiple surgical procedures, report only the anesthesia code for the most complex service; base units apply only to the primary procedure.

If two separate anesthesia codes are reported for the same anesthetic episode, the procedure with the lesser charge will be denied.

Exceptions

Add-on codes 01953, 01968, and 01969 are eligible for separate reimbursement in addition to the primary procedure.
If review of the anesthesia record documents a separate subsequent operative session with more than one hour separation from the initial anesthesia, a second anesthesia service may be eligible for separate reimbursement.

Field avoidance & positioning

Field avoidance and positioning

Procedures around the head, neck, or shoulder girdle requiring field avoidance, or any procedure requiring a position other than supine or lithotomy, are assigned a minimum base value of 5 regardless of any lesser base value.

Unusual positioning is not eligible for additional reimbursement even when reported with modifier 22.

Oral surgery

Oral surgery anesthesia

Reimburse anesthesia for covered oral surgical procedures when reported with appropriate CDT anesthesia codes D9211–D9248.

CPT anesthesia codes 00170–00176 are not eligible for reimbursement when reported with CDT procedures; CDT anesthesia codes D9211–D9248 are not eligible for separate reimbursement when reported with CPT procedure codes.

When an oral surgeon reports a CPT procedure and also provides the anesthesia service, modifier 47 must be appended; in that instance no additional reimbursement for anesthesia will be made (only the oral surgery procedure is eligible).

Global reimbursement inclusions/exclusions

Services included or excluded in global anesthesia reimbursement

Global reimbursement for anesthesia includes all procedures integral to administration of anesthesia from pre-anesthesia evaluation through end of personal attendance and such services are not eligible for separate reimbursement.

Services specifically included (not separately reimbursable)

Daily hospital management of patient-controlled analgesia.
Echocardiography and electroencephalogram.
Inhalation treatments, laryngoscopy, and bronchoscopy procedures.
Placement and interpretation of non-invasive monitoring and placement of endotracheal and nasogastric tubes; peripheral IV placement and medication administration; venipuncture and transfusion.

TEE/NCCI

TEE and NCCI edits

If TEE is performed as a distinct and independent procedure from the anesthesia service, the appropriate modifier must be appended to TEE codes in the 93312–93317 range to be eligible for separate reimbursement.

TEE services performed for monitoring purposes (e.g., CPT 93318) or guidance of transcatheter intracardiac/great vessel interventions (e.g., CPT 93355) are considered incidental to anesthesia per NCCI edit logic and are not separately reimbursable; a bypass modifier will not override this determination.

Postoperative pain management

Postoperative pain management injections or catheter insertions by an anesthesiologist (e.g., CPT ranges 62320–62327 and 64400–64450) are eligible for separate reimbursement; time units are not applicable.

When performed bilaterally, report the unilateral code once with modifier 50; reimbursement will equal 150% of the allowance for the code (the service is considered one surgical service).

An epidural or major nerve injection or catheter insertion performed before, during, or after the surgical procedure is eligible for separate reimbursement in addition to the primary anesthesia code when the appropriate modifier is appended to indicate a distinct procedure.

CPT 01996 (daily hospital management of epidural/subarachnoid continuous drug administration) is payable once per date of service following surgery; when reported with anesthetic injection codes (e.g., 62320–62327), only the injection code is eligible for reimbursement and modifiers will not override this edit.

Anesthesia and postoperative pain management coverage rules

Coverage rules described in this portion of the policy:

Anesthesiologist postoperative pain management injections or catheter insertions (CPT 62320–62327, 64400–64450) are eligible for separate reimbursement and are not time-unit based.

When performed bilaterally, report the unilateral code once with modifier 50; reimbursement equals 150% of the allowance for the code.

CPT 01996 is eligible once per date of service following surgery; when billed with an anesthetic injection code (e.g., 62320–62327), only the injection code is reimbursed and modifiers will not override the edit.

TEE codes for monitoring or guidance (CPT 93318, 93355) are considered incidental to anesthesia per NCCI logic and are not separately reimbursable; bypass modifiers will not override.

Coverage rules

Key coverage positions and billing expectations from the policy text in these pages.

Provision of any medication in a facility setting (including Propofol) is considered part of the facility charge and is not eligible for separate reimbursement, even when reported with an unclassified or unspecified drug code (e.g., J3490).

Claims must use proper CPT/HCPCS codes, be fully supported in the medical record, and meet authorization and medical necessity guidelines appropriate to the procedure and the member's benefit terms; failure to follow coding/billing guidelines may result in rejection, denial, or recoupment.

These reimbursement policies are subject to federal, state, and CMS mandates and the member's benefit terms; Anthem reserves the right to review, revise, and recover payments in accordance with policy implementation.

Services must meet authorization and medical necessity requirements when applicable; prior authorization may be required per the member's benefit plan and state of residence.

Codes, Units, and Conversion Rules

Qualifying circumstance codesCPTCovered

99100	Anesthesia for patient of extreme age, younger than 1 year and older than 70
99116	Anesthesia complicated by utilization of the total body hypothermia.
99135	Anesthesia complicated by utilization of controlled hypotension.
99140	Anesthesia complicated by emergency conditions

Postoperative pain management codesCPTCovered

62320-62327	Epidural/major nerve injections and catheter procedures for postoperative pain management
64400-64450	Major peripheral nerve blocks for postoperative pain management

Postoperative pain management codesCPTCovered

62320-62327	Epidural/spinal injection codes referenced for postoperative pain management
64400-64450	Major peripheral nerve block injection codes referenced for postoperative pain management
01996	Daily hospital management of epidural/subarachnoid continuous drug administration

TEE codes incidental to anesthesiaCPTNot Covered

93318	TEE for monitoring purposes — considered incidental
93355	TEE for transcatheter intracardiac/great vessel structural intervention — considered incidental

Facility drug billingHCPCSNot Covered

J3490

Unclassified drug code example referenced for unclassified/unspecified drug reporting

inv-16: Time-to-units conversion — minutes reported divided by 15 and rounded to nearest tenth

Conversion methodMinutes reported divided by 15 and rounded to the nearest tenth to derive time units for reimbursement.

Reporting granularityAnesthesia time must be reported in one-minute increments and documented with start and stop times.

Use in calculationCalculated time units are used along with base units and conversion factor to determine reimbursement.

inv-17: Daily management with injection conflict — when CPT 01996 is billed with an anesthetic injection code only the injection code is eligible; modifier rules apply

Conflict ruleWhen CPT 01996 is billed with an anesthetic injection code (e.g., 62320-62327), only the injection code is eligible for reimbursement; modifiers will not override this edit.

Frequency limitCPT 01996 is payable once per date of service following the surgery date when eligible.

Denial conditionDaily hospital management (01996) will be denied when billed with a physical status modifier or qualifying circumstance procedure code.

inv-18: Time unit length — 15 minutes

Time unit lengthEach time unit equals an increment of fifteen (15) minutes.

Units per hourFour (4) time units per hour (60 minutes / 15-minute units).

Rounding basisMinutes are divided by 15 and rounded to the nearest tenth when converting to time units.

Billing, Documentation, and Authorization Responsibilities

Denial Risk

Modifier requirement and denial risk

Claims submitted for anesthesiology services without the appropriate modifier will be denied. Modifiers identifying who performed the anesthesia must be billed in the primary modifier field to receive appropriate reimbursement. The total reimbursement for anesthesia services provided by a physician/anesthesiologist and a non-physician anesthesia provider will not exceed 100% of the allowed amount.

Documentation Required

Time reporting and documentation

Providers must report anesthesia services in one-minute increments and note minutes in the units field. To calculate reimbursement for time, the number of minutes reported is divided by 15 and rounded to the nearest tenth. Anesthesia claims submitted with an indicator other than minutes may be rejected or denied. Start and stop times must be documented in the member's medical record. Anesthesia time starts with the preparation of the member for administration of anesthesia and stops when the anesthesia provider is no longer in personal attendance. Anesthesia time can be counted in blocks if there is an interruption in anesthesia, as long as the time counted reflects continuous anesthesia services provided.

Billing Rule

TEE incidental to anesthesia

If transesophageal echocardiography (TEE) services are provided for monitoring purposes (e.g., CPT 93318) or for guidance of a transcatheter intracardiac or great vessel structural intervention (e.g., CPT 93355), Anthem will follow NCCI edit logic and consider these codes incidental to the primary procedure. A bypass modifier will not override NCCI edits.

Affected example codes: CPT 93318, 93355

Prior Authorization

Postoperative pain management billing guidance

Postoperative pain management services (for example, CPT 62320-62327 and 64400-64450) performed by an anesthesiologist, such as injections or catheter insertions into the epidural space or major nerve, are eligible for separate reimbursement and are not billed with time units. When performed bilaterally, report the unilateral code once with modifier 50. The pain management code will be considered one surgical service and reimbursed at 150% of the allowance for the code. An epidural or major nerve injection or catheter insertion for postoperative pain management performed before, during, or after the surgical procedure is eligible for separate reimbursement in addition to the primary anesthesia code; the appropriate modifier must be appended to indicate a distinct procedural service. Daily hospital management of epidural or subarachnoid continuous drug administration (CPT 01996) is eligible once per date of service following the surgery date, but when reported with an anesthetic injection code (e.g., CPT 62320-62327) only the injection code is eligible for reimbursement. Modifiers will not override these edits. The health plan will deny daily management codes when billed with a physical status modifier or qualifying circumstance procedure code.

Covered codes/ranges: 62320-62327, 64400-64450
When bilateral: append modifier 50 and report once
Daily management CPT 01996: eligible once post-op but not payable when billed with injection codes; modifiers do not override edits

Prior Authorization

Authorization and medical necessity

Services must meet authorization and medical necessity guidelines and member benefit rules; failure to follow coding/billing guidelines may result in claim rejection, denial, or recovery/recoupment of payments.

Key Terms and Unit Definitions

inv-24: Physical Status Modifiers identify a specific physical condition that indicates an added level of complexity to the anesthesia service and may carry assigned unit values per ASA recommendation.

DefinitionPhysical Status Modifiers identify a specific physical condition that indicates added complexity to the anesthesia service.

ASA guidanceAnthem follows the ASA recommendation that unit values may be assigned to physical status modifiers for additional reimbursement when appended to the base anesthesia code.

Modifier referenceSpecific anesthesia modifiers and their use are listed in the Related Coding section of the policy.

inv-25: Anesthesia time — starts with preparation and stops when provider no longer in personal attendance; reported in one-minute increments

Start/stopAnesthesia time starts with preparation of the member for administration of anesthesia and stops when the anesthesia provider is no longer in personal attendance.

Reporting incrementReport anesthesia time in one-minute increments; document start and stop times in the medical record.

Interrupted sessionsAnesthesia time can be counted in blocks if interrupted, provided the time counted reflects continuous anesthesia services.

inv-26: Postoperative pain management — definition of postoperative pain management services by an anesthesiologist

ScopePostoperative pain management services by an anesthesiologist (e.g., injection or catheter insertion into the epidural space or major nerve) are eligible for separate reimbursement and are not time-unit based.

Eligible codesApplies to CPT codes/ranges 62320-62327 and 64400-64450.

Modifier requirementThe appropriate modifier must be appended to indicate a distinct procedural service when reported in addition to the primary anesthesia code.

inv-27: NCCI edit logic (incidental services) — National Correct Coding Initiative edits applied to determine when certain codes are incidental

NCCI applicationAnthem follows National Correct Coding Initiative (NCCI) edit logic to determine when certain codes are incidental to anesthesia and not separately reimbursable.

Modifier limitationA bypass or other modifier will not override NCCI edits that deem services incidental to anesthesia (e.g., specified TEE codes).

ExampleTEE codes used for monitoring or guidance (e.g., CPT 93318, 93355) are considered incidental per NCCI logic.

inv-28: Base Units (BU) — Base units assigned to specific anesthesia CPT codes derived from ASA RVG

DefinitionBase Units (BU) are assigned to a specific anesthesia CPT code and are derived from the American Society of Anesthesiologists (ASA) Anesthesia Relative Value Guide (RVG).

Role in reimbursementBase units form part of the ASA anesthesia formula used to calculate professional anesthesia reimbursement alongside time units and the conversion factor.

SourceBase unit assignments are based on the ASA RVG as referenced in the policy definitions.

inv-29: Conversion Factor (CF) — geographic-specific amount that varies by locality

DefinitionConversion Factor (CF) is a geographic-specific amount that varies by the locality where the anesthesia is administered.

UseThe conversion factor is applied to the sum of base units, physical status units, and time units to determine the reimbursement amount.

Local variationConversion factors differ by locality; providers must apply the applicable local CF for reimbursement calculations.

inv-30: Time Units (TU) — increments of fifteen (15) minutes where each 15-minute increment constitutes one (1) time unit

DefinitionTime Units (TU) are increments of fifteen (15) minutes where each 15-minute increment constitutes one (1) time unit.

ConversionReport minutes in one-minute increments; convert minutes to time units by dividing by 15 and rounding to the nearest tenth.

Billing roleTime units are combined with base units and conversion factor to calculate total anesthesia reimbursement; postoperative pain management is not time-unit based.

inv-31: General — General anesthesia definition

DefinitionGeneral anesthesia: drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation.

ContextGeneral anesthesia is one of the anesthesia types defined in the policy definitions for reimbursement context.

ImplicationSelection of anesthesia type and appropriate modifiers affects coding and reimbursement processing.

inv-32: Local — Local anesthesia definition

DefinitionLocal anesthesia: loss of sensation in a limited and superficial area of the body.

ScopeLocal anesthesia is defined separately from regional and general anesthesia for coding and coverage clarity.

Reimbursement noteAppropriate coding must reflect the type of anesthesia provided to ensure correct application of modifiers and payment rules.

inv-33: Regional — Regional anesthesia definition

DefinitionRegional anesthesia: delivery of anesthetic medication at a specific level of the spinal cord and/or to peripheral nerves used when loss of consciousness is not desired but sufficient analgesia and loss of voluntary and involuntary movement is required.

ExamplesIncludes epidural, spinal, and major peripheral nerve blocks relevant to postoperative pain management code ranges (e.g., 62320-62327, 64400-64450).

DocumentationRecord the procedure and any appended modifiers to support separate reimbursement when applicable.

Policy Revision History

2014-04-01revision

Updated section 6D to clarify facility medication reimbursement language and revised section 7 to specify 'postoperative' pain management; routine OB ICD-10 updates and minor editorial corrections applied.

2013-06-04revision

Removed obstetrical anesthesia section and clarified postop nerve block language; updated examples and coding references across multiple sections.

2013-03-05revision

Clarified field avoidance payment rules and updated coding for endotracheal and nasogastric tube placement; other editorial updates made.

2012-09-11revision

Affirmed that medication charges reported by an anesthesia provider in a facility setting are not eligible for separate reimbursement and updated modifier and coding language.

2011-06-21revision

Updated RV Guide footnote reference (2009 to 2010) and applied multiple coding and modifier clarifications including servicing modifiers and OB diagnosis codes.

2010-08-03revision

Adjusted TEE code handling by changing code range and adding note that 93318 is a 0-superscript code and modifier 59 will not override the edit.

2009-12-14revision

Clarified that CPT 01996 should not be reported with a physical status modifier or qualifying circumstances code and added related policy notes and sourcing footnote.

2009-09-14revision

Revised policy heading and policy history section as part of broader administrative updates.

2009-02-03initial_effectiveLatest

Policy initially approved and made effective.