Policy Number: C-09002; Subject: Anesthesia Services - Professional. Effective Date: 04/01/2026; Last Review Date: 01/01/2026.
Scope: Defines Anthem Blue Cross professional anesthesia reimbursement rules including use of the American Society of Anesthesiologists (ASA) anesthesia formula, National Correct Coding Initiative (NCCI) coding guidance, time reporting, modifier requirements, multiple-procedure handling, qualifying circumstances, oral surgery anesthesia rules, services included/excluded from global reimbursement, postoperative pain management, and medication billing restrictions in facility settings.
Background/High-level summary: Reimbursement follows the ASA anesthesia formula and NCCI logic. Time must be reported in one-minute increments and reimbursement time units are calculated as minutes ÷ 15, rounded to the nearest tenth. Anesthesia modifiers that identify the service or who performed it must be appended (and those identifying who performed the service must be in the primary modifier field); claims without appropriate modifiers may be denied and combined physician/non‑physician payment will not exceed 100% of the eligible amount for a physician alone.
Multiple procedures and modifiers: Only the anesthesia code for the most complex service is reported and base units apply to the primary procedure; add-on codes 01953, 01968, 01969 are eligible for separate reimbursement. If a separate subsequent operative session is documented with > 1 hour separation, a second anesthesia service may be considered separately payable. Physical status modifiers are recognized per ASA guidance for additional units when appended to base anesthesia codes.
Qualifying circumstances and oral surgery: Qualifying circumstance CPT codes (99100, 99116, 99135, 99140) are always bundled and not separately reimbursed. Oral surgery anesthesia: CDT anesthesia codes D9211–D9248 may be used for covered oral surgical procedures; CPT intraoral anesthesia codes 00170–00176 are not eligible when reported with CDT procedures, and CDT anesthesia codes are not separately reimbursable when reported with CPT procedure codes. If an oral surgeon reports a CPT procedure and also provides anesthesia, modifier 47 is required but anesthesia receives no additional reimbursement.
Global vs separate reimbursement and drugs: Certain services (e.g., echocardiography, EEG, inhalation treatments, placement/interpretation of non-invasive monitoring, intubation, peripheral IV placement, venipuncture/transfusion, and one-day preop/10-day postop E/M) are included in global anesthesia reimbursement and not payable separately, while specified postoperative nerve block/injection codes (e.g., 62320–62327, 64400–64450) may be eligible for separate reimbursement. When a professional provider separately reports medications in a facility setting (including Propofol), the medication is not eligible for separate reimbursement and is considered included under the facility's charge.
TEE and postoperative pain management specifics: TEE codes 93312–93317 may be eligible for separate reimbursement only when performed as a distinct and independent procedure with an appropriate modifier; monitoring/guidance codes such as 93318 and 93355 are considered incidental per NCCI logic and a bypass modifier will not override. Postoperative pain management injections/catheter insertions are eligible for separate reimbursement (time units not applicable); CPT 01996 (daily hospital management) is eligible once per date of service following surgery but will be denied when billed with a physical status modifier or qualifying circumstance codes and will not pay when reported with certain injection codes.