ModifiedAnthemPolicy C-09002

Anesthesia Services

Defines Anthem commercial professional reimbursement rules for anesthesia services including time reporting, modifiers (physical status and servicing), multiple procedures, field avoidance, qualifying circumstances, oral surgery anesthesia interactions with CDT/CPT, global/included services, postoperative pain management, and related coding rules effective for Anthem members.

Policy Summary

PayerAnthem

PolicyAnesthesia Services

Policy CodePolicy C-09002

Change TypeModified (bundling clarification; modifiers added)

Effective DateMar 1, 2025

Next Review DateN/A

Key ActionReport anesthesia services in one-minute increments and document start and stop times; append servicing modifier in the primary modifier field and appropriate physical status modifier when applicable.

SourceLink

POLICY UPDATE CHANGES

Updated policy title and bundling language for qualifying circumstances (qualifying circumstance codes are always bundled).

Clarified that qualifying circumstance CPT codes (99100, 99116, 99135, 99140) are always bundled and not eligible for separate reimbursement.

Added modifiers G8, G9, QS to the related coding list and updated language on physical status modifiers.

4Qualifying circumstance CPT codes bundled

62320-62327Postoperative pain management codes eligible separately

00170-00176CPT intraoral anesthesia codes not eligible with CDT

P3-P5Physical status modifiers with additional reimbursement

Policy overview

Payer: Anthem. This policy (Professional Anesthesia Services, Policy Number C-09002) describes Anthem’s professional anesthesia reimbursement rules — based on the ASA anesthesia formula and NCCI logic — for time reporting, modifier use, multiple procedures, field avoidance/positioning, qualifying circumstances, oral surgery interactions between CPT and CDT anesthesia codes, services included in the global anesthesia reimbursement, and postoperative pain management. Effective date: 03/01/2025. Last review/approval: 11/26/2024. Covered topics include: requirements to report anesthesia time in minutes and conversion to 15-minute time units; proper placement and effect of servicing and physical status modifiers; rules for billing only the most complex anesthesia procedure (with specified add-on exceptions); minimum base value for field avoidance/positioning; qualifying circumstance codes that are always bundled and not separately reimbursable; restrictions when CPT intraoral anesthesia codes and CDT dental anesthesia codes are reported together; items and procedures included in the global anesthesia allowance (and exceptions such as separate reimbursement rules for distinct TEE and select catheter/line insertions); and separate reimbursement rules for postoperative pain management injections and catheter care.

Policy NumberC-09002

Effective Date2025-03-01

Last Review2024-11-26

Next Review

StatusMODIFIED

Scope SummaryDefines Anthem commercial professional reimbursement rules for anesthesia services including time reporting, modifiers, multiple procedures, field avoidance, qualifying circumstances, oral surgery interactions, global/included services, postoperative pain management, and related coding rules.

Time unit conversion thresholdDivide minutes reported by 15 and round up to the next unit (e.g., 61 minutes -> 5 units)

Coverage criteria and inclusion/exclusion rules

Time Reporting and Reimbursement Calculation

Anesthesia time reporting and reimbursement calculation requirements and formula.

Time reporting and calculation: Report anesthesia services in one-minute increments; document start and stop times

Claims submitted with an indicator other than minutes may be rejected or denied; time starts with preparation and stops when provider no longer in personal attendance; interruptions may be aggregated if continuous anesthesia time is documented

Time unit conversion: Convert minutes to time units by dividing minutes by 15 and rounding up to the next unitExample: 61 minutes -> 5 units

Providers should report time units only; base units are added by the Health Plan

Reimbursement formula: Reimbursement allowance = (time units + base units) x contracted conversion factor

Code lists and coding guidance

Qualifying circumstance codes (always bundled, not eligible for separate reimbursement)CPTNot Covered

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.

Oral surgery CDT anesthesia codes (allowed when reported alone)HCPCSCovered

D9211	Anesthesia for procedures on salivary glands, including biopsy (CDT range D9211 - D9248 allowed for covered oral surgical procedures).
D9212	Anesthesia for complex oral surgical procedures (CDT range D9211 - D9248).
D9248	Other anesthesia for dental procedures (CDT range D9211 - D9248).

CPT anesthesia codes not eligible with CDT on same claimCPTNot Covered

00170	Anesthesia for intraoral procedures — not eligible for reimbursement when reported with CDT procedures (D9211-D9248).
00171	Anesthesia for procedures on the oral cavity — not eligible with CDT on same claim.
00172	Anesthesia for dental procedures — not eligible with CDT on same claim.
00173	Anesthesia for oral surgical procedures — not eligible with CDT on same claim.
00174	Anesthesia for extensive dental procedures — not eligible with CDT on same claim.
00175	Anesthesia for oral procedures — not eligible with CDT on same claim.
00176	Anesthesia for intraoral procedures (other) — not eligible with CDT on same claim.

Postoperative pain management injection codes (eligible for separate reimbursement)CPTCovered

62320	Epidural or spinal injection for postoperative pain management (62320-62327 range eligible separately).
62321	62320-62327 range (spinal/epidural injections) eligible for separate reimbursement.
62322	62320-62327 range (spinal/epidural injections) eligible for separate reimbursement.
62323	62320-62327 range (spinal/epidural injections) eligible for separate reimbursement.
62324	62320-62327 range (spinal/epidural injections) eligible for separate reimbursement.
62325	62320-62327 range (spinal/epidural injections) eligible for separate reimbursement.
62326	62320-62327 range (spinal/epidural injections) eligible for separate reimbursement.
62327	62320-62327 range (spinal/epidural injections) eligible for separate reimbursement.
64400	Peripheral nerve block injection (64400-64450 range) eligible for separate reimbursement for postoperative pain management.
64401	64400-64450 range (peripheral nerve blocks) eligible for separate reimbursement.

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Daily hospital management of epidural/subarachnoid continuous drug administrationCPT

01996

Daily hospital management of epidural or subarachnoid continuous drug administration for postoperative pain management — reimbursed once per date following surgery; not reimbursed when billed with 62320-62327 (only injection reimbursed) and denied when billed with physical status or qualifying circumstance codes.

TEE codes (separate reimbursement only when distinct and independent procedure)CPT

93312	Transesophageal echocardiography with image acquisition, storage and reporting — eligible for separate reimbursement only when performed as distinct and independent procedure with appropriate modifier (codes 93312-93317).
93313	TEE code in 93312-93317 range — separate reimbursement requires distinct/independent procedure and appropriate modifier.
93314	TEE code in 93312-93317 range — separate reimbursement requires distinct/independent procedure and appropriate modifier.
93315	TEE code in 93312-93317 range — separate reimbursement requires distinct/independent procedure and appropriate modifier.
93316	TEE code in 93312-93317 range — separate reimbursement requires distinct/independent procedure and appropriate modifier.
93317	TEE code in 93312-93317 range — separate reimbursement requires distinct/independent procedure and appropriate modifier.
93318	TEE monitoring (e.g., 93318) is considered incidental under NCCI and not separately reimbursed; bypass modifier will not override.
93355	Echocardiography guidance of transcatheter interventions (e.g., 93355) considered incidental under NCCI and not separately reimbursed with anesthesia.

Modifiers referenced (physical status and servicing)Modifier

P1	Normal healthy patient (recognized; no additional reimbursement).
P2	Mild systemic disease (recognized; no additional reimbursement).
P3	Severe systemic disease (108% reimbursement when accompanied by servicing modifier).
P4	Severe systemic disease that is a constant threat to life (112% when accompanied by servicing modifier).
P5	Moribund patient (116% when accompanied by servicing modifier).
P6	Declared brain-dead donor (recognized; no additional reimbursement).
G8	Informational modifier (added to related coding list).
G9	Informational modifier (added to related coding list).
QS	Informational modifier (added to related coding list).
QK	Historically referenced modifier reduction.

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No codes listed

Billing, documentation, and denial risks

Billing Rule

Report anesthesia time in minutes

Report anesthesia services in one-minute increments; document start and stop times in the medical record and report minutes in the units field. Claims submitted with an indicator other than minutes may be rejected or denied.

Operational note: Claims submitted with an indicator other than minutes may be rejected or denied.

Billing Rule

Modifiers must be appended correctly

Append the servicing modifier in the primary modifier field and append the appropriate physical status modifier when applicable; claims submitted without the appropriate modifier will be denied.

Claims without appropriate servicing/physical status modifier will be denied.
Physical status modifiers that increase reimbursement when accompanied by a servicing modifier: P3 = 108%, P4 = 112%, P5 = 116%.

Definitions and references

Base Units (BU)Base Units assigned to a specific anesthesia CPT code derived from the ASA Anesthesia Relative Value Guide.

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

Time Units (TU)An increment of fifteen (15) minutes where each 15-minute increment constitutes one (1) time unit.

AnesthesiaDrugs or substances that cause a loss of consciousness or sensitivity to pain.

References: CMS; Optum EncoderPro 2024; ASA Anesthesia Relative Value Guide. Note: Anthem’s policy follows the ASA anesthesia formula for base units and conversion calculations and applies NCCI logic for inclusion/exclusion of services and incidental procedure edits, as stated in the policy background and history.

Policy revision history

2016-01-05revised

Added modifiers G8, G9, and QS to the modifiers table and clarified reporting instructions for these informational modifiers.

2024-11-26revisedLatest

Updated policy title from Professional Anesthesia Services, added Physical Status modifiers language, and updated language for qualifying circumstances to always bundle. Noted as a material change.

2024-11-26clarifiedLatest

Policy Summary

PayerAnthem

PolicyAnesthesia Services

Policy CodePolicy C-09002

Change TypeModified (bundling clarification; modifiers added)

Effective DateMar 1, 2025

Next Review DateN/A

SourceLink

On This Page

Base units are assigned per ASA RVG and are automatically added by the Health Plan

Anesthesia Modifiers and Physical Status Modifiers

Modifier requirements, servicing modifier placement, and physical status modifier payment effects.

Modifier append and placement: Append appropriate anesthesia servicing and physical status modifiers to the anesthesia procedure code; servicing modifier must be billed in the primary modifier field

Claims submitted without appropriate modifier will be denied; total reimbursement for physician + non-physician providers will not exceed 100% of amount allowed had physician provided service alone

Physical status modifiers with additional reimbursement: P3 = 108%

Additional reimbursement applies when physical status modifier is appended to base anesthesia code and accompanied by a servicing modifier

Physical status modifiers with additional reimbursement: P4 = 112%

Additional reimbursement applies when physical status modifier is appended to base anesthesia code and accompanied by a servicing modifier

Physical status modifiers with additional reimbursement: P5 = 116%

Additional reimbursement applies when physical status modifier is appended to base anesthesia code and accompanied by a servicing modifier

Recognized physical status modifiers without additional reimbursement: P1, P2, P6 are recognized but receive no additional reimbursement

Recognition requires accompaniment by a servicing modifier; no pay percent assigned

Multiple Procedures

Rules when multiple procedures occur during the same anesthesia session and exceptions for add-on codes.

Primary procedure selection: Report only the anesthesia procedure code for the most complex service; base units applied only to the primary procedure

If two separate anesthesia codes are reported, the procedure with the lesser charge will be denied

Exception add-on codes: Add-on codes 01953, 01968, and 01969 are eligible for separate reimbursement in addition to the primary procedure

These add-on codes are listed separately and permitted as exceptions to the single-primary rule

Separate subsequent session exception: A second anesthesia service may be eligible for separate reimbursement if Health Plan determines a separate subsequent operative session occurred with more than one hour separation from the initial anesthesia>1 hour separation

Eligibility based on review of anesthesia record

Field Avoidance and Unusual Positioning

Minimum base value for procedures requiring field avoidance or unusual positioning and modifier 22 exclusion.

Minimum base value for field avoidance/positioning: Procedures around head, neck, or shoulder girdle requiring field avoidance, or procedures requiring a position other than supine or lithotomy, have a minimum base value of 5 regardless of a lesser assigned base valueMinimum base value = 5

This minimum applies regardless of assigned base units for the procedure

Modifier 22 exclusion for unusual positioning: Unusual positioning is not eligible for additional reimbursement even when reported with modifier 22

Modifier 22 will not result in additional payment for unusual positioning

Qualifying Circumstances

Qualifying circumstance codes are bundled and not eligible for separate reimbursement.

Qualifying circumstance bundling: Qualifying circumstance CPT codes are always bundled when reported in addition to the anesthesia procedure and are not eligible for separate reimbursement

The policy explicitly lists qualifying circumstance codes below

Listed qualifying circumstance codes: 99100; 99116; 99135; 99140

99100 = extreme age; 99116 = total body hypothermia; 99135 = controlled hypotension; 99140 = emergency conditions

Anesthesia for Oral Surgery

Interaction rules between CPT anesthesia codes and CDT dental anesthesia codes for oral surgery and modifier 47 handling.

Allowed when reported with CDT codes: Anesthesia for covered oral surgical procedures is allowed when reported with appropriate CDT-based anesthesia codes D9211 - D9248

CDT anesthesia codes are permitted when reported alone for covered oral surgery

CPT 00170-00176 exclusion with CDT: CPT anesthesia codes 00170 - 00176 will not be eligible for reimbursement when reported with CDT procedures on the same claim

Do not report CPT intraoral anesthesia codes on a claim with CDT anesthesia codes

CDT not eligible when reported with CPT: CDT anesthesia codes D9211 - D9248 will not be eligible for separate reimbursement when reported with CPT procedure codes

CDT codes are excluded from separate reimbursement if CPT procedures are reported on same claim

Modifier 47 when oral surgeon provides anesthesia: When an oral surgeon reports the CPT procedure and also provides anesthesia, modifier 47 must be appended; no additional anesthesia reimbursement will be allowed

Only the oral surgery procedure is eligible for reimbursement in this scenario

Services Included/Excluded in Global Reimbursement for Anesthesia

Services included in the global anesthesia reimbursement (not separately payable) and enumerated exceptions eligible for separate reimbursement; medication charge note.

Global services included (not separately reimbursable): Global anesthesia reimbursement includes services integral from pre-anesthesia evaluation through end of personal attendance; examples not separately reimbursable include daily hospital management of PCA, echocardiography, EEG, inhalation treatments, laryngoscopy/bronchoscopy, non-invasive monitoring placement/interpretation, endotracheal/nasogastric tube placement, peripheral IV placement/administration, venipuncture/transfusion

These services are considered included under NCCI logic and not paid separately

Nerve block injections exception: Nerve block injections for pain management are eligible for separate reimbursement

Nerve block injections are specifically carved out as eligible for separate payment

Enumerated separately reimbursable procedures: Separate reimbursement allowed for Swan-Ganz catheter insertion, central venous pressure line insertion, intra-arterial lines, and transesophageal echocardiography (TEE) when performed as a distinct and independent procedure with appropriate modifier appended to 93312-93317

TEE monitoring codes (e.g., 93318) and codes for guidance of transcatheter interventions (e.g., 93355) are considered incidental and are not separately reimbursable; bypass modifiers will not override

Medication charges in facility setting: When a professional provider separately reports a medication in a facility setting, the medication will not be eligible for separate reimbursement

Includes Propofol; facility's charge includes medications and separate reporting by professional provider may be denied

Postoperative Pain Management

Postoperative pain management separate reimbursement rules, bilateral reporting, and 01996 constraints.

Eligible injection/catheter codes: Postoperative pain management injections and catheter insertions (CPT codes 62320-62327 and 64400-64450) by an anesthesiologist are eligible for separate reimbursement; time units do not apply

Applies to listed code ranges

Bilateral reporting and reimbursement: When performed bilaterally, report the unilateral code once with modifier 50; reimbursement will equal 150% of the allowance for the code

The unilateral code is treated as one surgical service for payment at 150%

01996 daily management rules: CPT 01996 (daily hospital management of epidural/subarachnoid continuous drug administration) is eligible for reimbursement once per date of service following the surgery date; however, if 01996 is reported with an anesthetic injection code (62320-62327), only the injection code is eligible for reimbursementOne reimbursement of 01996 per date following surgery; excluded when billed with 62320-62327

Modifiers will not override these edits; Health Plan will deny 01996 when billed with a physical status modifier or qualifying circumstance codes

Billing Rule

Do not separately bill qualifying circumstance codes

Qualifying circumstance CPT codes (99100, 99116, 99135, 99140) are always bundled and are not eligible for separate reimbursement.

99100
99116
99135
99140

Billing Rule

Oral surgery anesthesia billing restrictions

Do not report CPT anesthesia codes 00170-00176 on the same claim with CDT anesthesia codes D9211-D9248; if an oral surgeon reports the CPT procedure and also provides anesthesia, append modifier 47 and no additional anesthesia reimbursement will be allowed.

Affected CPT range: 00170-00176
Affected CDT range: D9211-D9248
Note: When oral surgeon reports CPT procedure and also provides anesthesia, modifier 47 must be appended and no additional anesthesia reimbursement is allowed.

Billing Rule

Multiple anesthesia procedures

When multiple anesthesia procedures occur, report only the anesthesia code for the most complex service; secondary anesthesia procedure codes will be denied except for specified add-on codes which are eligible for separate reimbursement.

Add-on codes eligible for separate reimbursement: 01953, 01968, 01969

Documentation Required

Document anesthesia start/stop times and continuous service interruptions

Maintain medical record documentation of anesthesia start and stop times and document continuous anesthesia time if interruptions are aggregated for billing.

Example: 61 minutes -> 5 units (divide minutes by 15 and round up)

Billing Rule

Postoperative pain management billing

Postoperative pain management injections (epidural or major nerve injection/catheter) reported with codes 62320-62327 and 64400-64450 are eligible for separate reimbursement; bilateral services should be reported once with modifier 50 and reimbursed at 150%, and daily management code 01996 is reimbursed once per date following surgery but is not paid when billed with injection codes 62320-62327.

Postoperative injection code ranges: 62320-62327
Peripheral nerve block range: 64400-64450
Daily hospital management: 01996 (one per date following surgery; excluded when billed with 62320-62327)
Bilateral reporting: report unilateral code once with modifier 50; reimbursement = 150% of allowance

Denial Risk

Medication charges in facility setting

Medications reported separately by a professional provider in a facility setting (for example, Propofol) are considered part of the facility's charge and are not eligible for separate reimbursement and may be denied.

Clarified that qualifying circumstance CPT codes (99100, 99116, 99135, 99140) are always bundled and not eligible for separate reimbursement.

2024-11-26added

Added modifiers G8, G9, QS to the Related Coding section code list.