Anthem Anesthesia Coverage Update: Modifiers & Time

Policy Number: C-09002; Subject: Anesthesia Services - Professional Reimbursement Policy. Anthem bases professional anesthesia reimbursement on the American Society of Anesthesiologists (ASA) anesthesia formula and follows National Correct Coding Initiative (NCCI) guidance where noted. The policy defines rules for reporting anesthesia time (one-minute increments with minutes divided by 15 and rounded to the nearest tenth), required documentation of start/stop times, and use of anesthesia and physical status modifiers to indicate complexity or performer. Modifier placement requirements (performer modifiers must be billed in the primary modifier field) and limits on combined physician/non-physician reimbursement (total not to exceed 100% of the physician-only eligible amount) are specified.

The policy covers multiple procedures (report only the anesthesia code for the most complex service; base units used only for the primary procedure; exception for add-on codes 01953, 01968, 01969 which are eligible for separate reimbursement), qualifying circumstances (codes such as 99100, 99116, 99135, 99140 are bundled and not separately reimbursed), field avoidance/minimum base values (procedures around head/neck/shoulder requiring field avoidance or non-supine positions carry a minimum base value of 5), and oral surgery coding interactions with CDT (CDT anesthesia codes D9211-D9248 allowed when CDT used; CPT intraoral anesthesia codes 00170-00176 are not eligible when reported with CDT and CDT codes are not separately reimbursable when reported with CPT).

Global reimbursement inclusions and exclusions (numerous monitoring, airway, IV/medication administration, one-day preop and 10-day postop E/M included; nerve block injections are eligible separately) and postoperative pain management rules are specified: epidural/major nerve injection or catheter codes (62320-62327, 64400-64450) may be reimbursed separately (bilateral reporting guidance with modifier 50 results in payment equal to 150% of the allowance), and daily hospital management code 01996 is payable once per date of service but subject to edits when billed with injections or physical status/qualifying circumstance codes. Finally, medications reported separately by anesthesia professionals in facility settings (including Propofol) are considered included in the facility charge and are not eligible for separate professional reimbursement.

Coverage & clinical criteria

Time Reporting and Reimbursement Calculation

Anesthesia time and reimbursement are governed by the following rules:

ALL of the following

Time reporting in minutes: Report anesthesia services in one-minute increments and note minutes in the units field.
Time-to-units conversion: Reimbursement for time: number of minutes reported divided by 15 and rounded to the nearest tenth to provide a unit of measure.Minutes reported / 15, rounded to nearest tenth
Claim indicator requirement: Claims submitted with an indicator other than minutes may be rejected or denied.
Documentation of start/stop: Start and stop times must be documented in the member's medical record.
Definition of anesthesia time: Anesthesia time starts with preparation of the member for administration of anesthesia and stops when the anesthesia provider is no longer in personal attendance.
Interrupted anesthesia: Anesthesia time can be counted in blocks if interrupted, as long as counted time is continuous anesthesia services provided.

Anesthesia Modifiers and Servicing Modifiers

Modifiers must be used correctly to indicate service and performer:

ALL of the following

Append modifiers to procedure code: Append appropriate anesthesia modifiers to the applicable procedure code to indicate specific anesthesia service or who performed the service.
Primary modifier field requirement: Modifiers identifying who performed the anesthesia must be billed in the primary modifier field to receive appropriate reimbursement.
Claims without modifier: Claims submitted without the appropriate modifier will be denied.
Aggregate reimbursement cap: Total reimbursement for anesthesia services provided by physician and non-physician anesthesia provider will not exceed 100% of the eligible amount that would be allowed had the service been provided by only the physician/anesthesiologist.

Physical Status Modifiers

Physical status modifiers indicate added complexity and have unit values per ASA guidance:

ALL of the following

ASA unit values for physical status: Plan follows ASA recommendation that unit values are assigned to physical status modifiers for additional reimbursement when appended to the base anesthesia code.
See related coding: Specific physical status modifiers and assigned units are listed in the related coding section.

Field Avoidance and Unusual Positioning

ALL of the following

Minimum base value for field avoidance: Procedures around head, neck, or shoulder girdle requiring field avoidance, or procedures requiring positions other than supine or lithotomy, have a minimum base value of 5 regardless of lesser assigned base value.Base value >= 5
Unusual positioning not reimbursed: Unusual positioning is not eligible for additional reimbursement even when reported with modifier 22.

Anesthesia for Oral Surgery (CPT vs CDT)

Oral surgery anesthesia interactions with CPT and CDT:

ALL of the following

CDT anesthesia allowed with CDT procedures: Reimbursement allowed for anesthesia for covered oral surgical procedures reported with CDT-based anesthesia codes D9211 - D9248.
CPT intraoral anesthesia not eligible with CDT: CPT anesthesia codes 00170 - 00176 (anesthesia for intraoral procedures) are not eligible for reimbursement when reported with CDT procedures.
CDT anesthesia not eligible with CPT: CDT anesthesia codes D9211 - D9248 are not eligible for separate reimbursement when reported with CPT procedure codes.
Modifier 47 for oral surgeons:

Global Reimbursement Inclusions/Exclusions

Services included in global anesthesia reimbursement and not eligible for separate reimbursement:

ALL of the following

Included services (not separately reimbursed)
- Patient-controlled analgesia management: Daily hospital management of patient-controlled analgesia (when patient controls amount received).
- Echocardiography.
- Electroencephalogram.
- Inhalation treatments.

Medications Reported by Professional Provider in Facility

ALL of the following

Medications in facility not reimbursed separately: When an anesthesia professional provider separately reports a medication in a facility setting, the medication will not be eligible for separate reimbursement even when reported with an unclassified or unspecified drug code.
Propofol example: Provision of any medication, including Propofol, is considered included under the facility's charge.

Services Eligible for Separate Reimbursement

Certain invasive monitoring and lines may be reimbursed separately if appropriately reported:

ALL of the following

Separate reimbursement allowed for invasive lines/TEE: Separate reimbursement allowed for Swan-Ganz catheter insertion, central venous pressure line insertion, intra-arterial lines, and transesophageal echocardiography (TEE) if performed as distinct and independent procedures.
TEE modifier requirement: If TEE (CPT codes 93312-93317) is distinct and independent from anesthesia service, appropriate modifier must be appended to TEE code to be eligible for separate reimbursement.
Incidental TEE codes: If TEE services are for monitoring purposes (e.g., CPT 93318) or for guidance of transcatheter intracardiac or great vessel structural interventions (e.g., CPT 93355), the plan will follow NCCI logic, consider those codes incidental, and bypass modifier will not override.

Postoperative Pain Management

Rules for reimbursement of postoperative pain management services:

ALL of the following

Eligible post-op pain management codes: Postoperative pain management services by an anesthesiologist (e.g., injection or catheter insertion into epidural space or major nerve) are eligible for separate reimbursement; time units are not applicable.Applies to codes/ranges: 62320-62327, 64400-64450
Bilateral reporting and payment: When performed bilaterally, report the unilateral pain management code once with modifier 50 using the applicable base value for the unilateral code; payment equals 150% of the allowance for the code.150% of allowance when modifier 50 appended
Distinct procedural service requirement: Epidural or major nerve injection or catheter insertion performed by an anesthesiologist for postoperative pain management before, during, and/or following the surgical procedure is eligible for separate reimbursement in addition to the primary anesthesia code when appropriate modifier appended to indicate a distinct procedural service.

Code lists and status

Qualifying Circumstance CPT Codes (bundled/not separately reimbursed)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.

Add-on Anesthesia Codes Eligible for Separate ReimbursementCPTCovered

01953	Add-on code eligible for separate reimbursement in addition to primary procedure.
01968	Add-on code eligible for separate reimbursement in addition to primary procedure.
01969	Add-on code eligible for separate reimbursement in addition to primary procedure.

Oral Surgery CDT Anesthesia Codes (allowed when CDT used)mixedCovered

D9211-D9248

CDT anesthesia codes for oral surgical procedures; reimbursable when reported with CDT-based oral surgical procedures.

CPT Anesthesia Codes Not Eligible with CDTCPTNot Covered

00170-00176

CPT anesthesia codes for intraoral procedures not eligible for reimbursement when reported with CDT procedures.

Postoperative Pain Management Codes (eligible separately)CPTCovered

62320-62327	Epidural and intrathecal injection/insertion codes; eligible for separate reimbursement for postoperative pain management.
64400-64450	Major peripheral nerve block injection codes; eligible for separate reimbursement for postoperative pain management.
01996	Daily hospital management of epidural or subarachnoid continuous drug administration; eligible once per date of service following surgery but subject to edits (not payable with anesthetic injection codes 62320-62327 and denied when billed with physical status or qualifying circumstance codes).

TEE and Related Codes (separate reimbursement conditions)CPT

93312-93317	Transesophageal echocardiography codes; reimbursable separately if distinct and independent from anesthesia and appropriate modifier appended.
93318	TEE monitoring code; considered incidental to anesthesia when used for monitoring and not separately reimbursable per NCCI.
93355	TEE guidance of transcatheter intracardiac/great vessel structural interventions; considered incidental per NCCI and not separately reimbursable.

Coding notes: NCCI edit logic is applied to determine when services are incidental versus eligible for separate reimbursement (for example, TEE monitoring codes used for monitoring or guidance such as CPT 93318 and 93355 are considered incidental per NCCI and are not separately reimbursable unless performed as a distinct and independent procedure with appropriate modifier for codes 93312-93317.).

When CDT-based oral surgery is reported, certain CPT anesthesia codes are bundled and not eligible: CPT intraoral anesthesia codes 00170-00176 are not eligible when reported with CDT procedures, and CDT anesthesia codes D9211-D9248 are not separately reimbursable when reported with CPT procedure codes. Oral surgeons who provide anesthesia with a CPT oral surgery procedure must append modifier 47, and no additional anesthesia reimbursement will be provided.

Reminder on modifier placement and add-on codes: performer-identifying anesthesia modifiers must be billed in the primary modifier field to receive appropriate reimbursement; add-on anesthesia codes 01953, 01968, 01969 are treated as separately reimbursable in addition to the primary procedure. Claims submitted without proper modifiers or using non-minute time indicators may be rejected or denied.

Required billing, documentation, and denial risks

Billing Rule

Report anesthesia time in minutes and calculate units

Report anesthesia services in one-minute increments and enter minutes in the units field. Convert reported minutes to time units by dividing the number of minutes by 15 and rounding to the nearest tenth for reimbursement.

Start/stop times must be documented
Claims with non-minute indicators may be denied

Billing Rule

Append performer modifiers in primary modifier field

Append modifiers that identify who performed the anesthesia in the primary (first) modifier field to receive appropriate reimbursement. Claims submitted without the appropriate performer modifier will be denied. When services are provided by both a physician and a non-physician anesthesia provider, total reimbursement will not exceed 100% of the amount that would be allowed had the physician provided the service alone.

Missing or incorrect performer modifier may result in denial
Combined physician + non-physician reimbursement capped at 100%

Documentation Required

Start/stop times documentation

Document the anesthesia start and stop times in the member's medical record to substantiate the reported minutes. Anesthesia time begins with preparation for administration of anesthesia and ends when the anesthesia provider is no longer in personal attendance.

Billing Rule

Multiple procedures reporting

When multiple surgical procedures are performed under anesthesia, report only the anesthesia code for the most complex service; base units apply to the primary procedure only. If two separate anesthesia codes are reported, the lesser-priced procedure will be denied. Exception: add-on codes 01953, 01968, and 01969 are eligible for separate reimbursement in addition to the primary procedure.

Add-on codes eligible separately: 01953, 01968, 01969
If two anesthesia codes are billed, the lesser will be denied

Billing Rule

Oral surgery coding

Do not report CPT anesthesia codes 00170-00176 with CDT procedures; CPT intraoral anesthesia codes are not eligible for reimbursement when reported with CDT procedures. CDT anesthesia codes D9211–D9248 are not separately reimbursable when reported with CPT procedure codes. If an oral surgeon reports a CPT oral surgery procedure and also provides anesthesia, append modifier 47 — there is no additional reimbursement for the anesthesia service.

Do not report CPT 00170-00176 with CDT procedures
CDT D9211-D9248 are not separately reimbursable with CPT codes
Oral surgeons must append modifier 47; no extra anesthesia reimbursement

Billing Rule

Medication charges in facility

Medication charges reported separately by anesthesia professionals in a facility setting are considered included in the facility's charge and are not eligible for separate reimbursement. This includes medications such as Propofol.

Billing Rule

TEE separate reimbursement conditions

Transesophageal echocardiography (TEE) codes 93312–93317 may be reimbursed separately only if the TEE is performed as a distinct and independent procedure and the appropriate modifier is appended. Per NCCI logic, TEE monitoring (e.g., CPT 93318) and guidance codes such as 93355 are considered incidental to the anesthesia service and are not separately reimbursable; a bypass modifier will not override that edit.

93312-93317 reimbursable if distinct and modifier appended
93318 and 93355 are incidental per NCCI and not separately reimbursable

Billing Rule

Postoperative pain management billing

Postoperative pain management injection and catheter codes (CPT 62320–62327 and 64400–64450) are eligible for separate reimbursement when appropriately reported; time units do not apply. For bilateral procedures, report the unilateral code once with modifier 50 and payment will equal 150% of the allowance. CPT 01996 (daily hospital management of continuous epidural/subarachnoid drug administration) is eligible once per date of service following the surgery but will be denied when billed with a physical status modifier or qualifying circumstance codes; when 01996 is billed with an anesthetic injection code such as 62320–62327 only the injection code is payable and modifiers will not override edits.

Report 62320-62327 and 64400-64450 for separate reimbursement
Bilateral: report unilateral code once with modifier 50; payment = 150%
01996 payable once per DOS but denied with physical status or qualifying circumstance codes
01996 not payable when billed with injection codes like 62320-62327

OpenPayer

Anesthesia Services Eff 4.1.26

Policy overview

Coverage & clinical criteria

Code lists and status

Required billing, documentation, and denial risks

Key definitions

Operational thresholds

Policy changes