CurrentAnthemPolicy G-07018

Professional Anesthesia Services Reimbursement

Defines Anthem HealthKeepers, Inc. reimbursement rules for professional anesthesia services for covered members, including billing, time reporting, modifiers, and allowable or nonreimbursable services. Applies to providers submitting claims under the insurer's plans.

Policy Summary

PayerAnthem

PolicyProfessional Anesthesia Services Reimbursement

Policy CodePolicy G-07018

Change TypeAdded qualifying circumstance codesadministrative updates

Effective Date11/06/2020

Next Review Date

Key ActionReport anesthesia claims in minutes with documented start and stop times and follow authorization and medical necessity guidelines.

SourceLink

POLICY UPDATE CHANGES

Allows reimbursement for qualifying circumstances codes denoting additional complexity levels or a patient of 'extreme age'.

Policy template updated; minor administrative updates and anesthesia modifier grid added.

Modifiers 23 & 47explicitly not reimbursed

Minutestime reporting

Flat rateobstetrical anesthesia

Multiplemultiple procedures

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Anesthesia reimbursement criteria

Covered when ALL of the following criteria and billing rules are met:

Anesthesia services are rendered by professional providers for covered members unless provider, state, federal, or CMS contracts and/or requirements indicate otherwise.

Reimbursement follows the applicable anesthesia allowance formula using base units, time increments, and conversion factors per state guidelines (or CMS defaults when no state requirement exists).

Providers must report anesthesia time in minutes with documented start and stop times in the medical record; anesthesia time begins with preparation of the member for administration and ends when the anesthesia provider is no longer in personal and continuous attendance.

Failure to report time in minutes may result in claim rejection or denial.

Anesthesia modifiers identifying who performed the service must be billed in the primary modifier field; additional or reduced payment for modifiers follows state rules or CMS guidelines when no state requirement exists.

When multiple anesthesia procedures are performed during the same session, reimbursement is based on the anesthesia procedure with the highest base unit value plus the overall anesthesia time for all procedures.

Neuraxial epidural anesthesia provided in conjunction with labor and delivery is reimbursed at a flat rate regardless of the number of minutes.

ALL of the following

Examples
- Swan-Ganz catheter insertion
- Central venous pressure line insertion
- Intra-arterial line insertion
- Emergency intubation (must be provided in conjunction with the anesthesia procedure)
- Critical care visits
- Transesophageal echocardiography

ALL of the following

Not reimbursed
- Anesthesia consultations on the same date as surgery or the day prior if part of the preoperative assessment
- Anesthesia services for noncovered procedures, including services considered not medically necessary, experimental, and/or investigational
- Anesthesia services by the provider performing the basic procedure, except a delivering physician providing continuous epidural analgesia
- Local anesthesia considered incidental to the surgical procedure
- Standby anesthesia services

Modifiers 23 and 47 are explicitly not reimbursed.

Coding, Modifiers, and Time Reporting

Nonreimbursable Anesthesia ModifiersModifierNot Covered

Modifier 23	Unrelated E/M service by the same physician during a procedure - not reimbursed
Modifier 47	Anesthesia by surgeon - not reimbursed

Time reporting — Anesthesia time

Required time unitAnesthesia services must be reported in minutes; claims submitted with an indicator other than minutes may be rejected or denied.

Reporting granularityRecord and submit documented start and stop times in the member's medical record.

Submission consequenceClaims using a non-minute time indicator risk rejection or denial.

Start/stop definitionAnesthesia 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.

Billing, Authorization, and Provider Responsibilities

Documentation Required

Billing, documentation, and modifier requirements for anesthesia claims

Follow authorization and medical necessity guidelines and report anesthesia time accurately on claims. Document and submit anesthesia start and stop times in the member's medical record and submit anesthesia claims in minutes; use the proper anesthesia modifiers with the modifier identifying who performed the service placed in the primary modifier field.

Anesthesia claims must be reported in minutes; 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 begins with preparation for administration and ends when the provider is no longer in personal and continuous attendance.
Use proper modifiers; modifiers identifying who performed the service should be in the primary modifier field.

Prior Authorization

Potential prior authorization required

Services may require prior authorization per state or contract requirements; ensure any required authorizations are obtained before providing services to avoid claim denials or recoupment.

Reimbursement policies may be superseded by provider, state, federal, or CMS contract requirements.
Services must meet authorization and medical necessity guidelines appropriate to the procedure, diagnosis, and member's state of residence.

Definitions and Units

Anesthesia — definition

DefinitionAnesthesia refers to drugs or substances that cause a loss of consciousness or sensitivity to pain.

Source guidanceDefinition provided in General Reimbursement Policy Definitions and references ASA and CMS in policy development.

ScopeApplies to professional anesthesia services reimbursed under this policy.

Base unit

Base unit definitionThe base unit is the relative value unit associated with each anesthesia procedure code as assigned by CMS.

Use in reimbursementUsed in the anesthesia reimbursement formula combined with time units and conversion factor.

Assignment authorityBase units correspond to CMS-assigned values for each anesthesia CPT code.

Time unit / Anesthesia time

Time unit incrementEach time unit equals a 15-minute increment; each 15-minute increment constitutes one time unit.

Time reporting requirementProviders must report anesthesia services in minutes; anesthesia time starts with preparation and ends when provider is no longer in personal and continuous attendance.

Claim submission noteAnesthesia claims submitted with an indicator other than minutes may be rejected or denied.

Conversion factor

Conversion factor definitionConversion factor is a geographic-specific amount that varies by the locality where the anesthesia is administered.

Role in reimbursementUsed in the reimbursement formula together with base units and reported anesthesia time per state guidelines.

Geographic variationLocality-specific conversion factors are applied per state or CMS guidance when determining anesthesia allowance.

Policy Revision History

2023-06-13review_approvedLatest

Review approved: policy template updated and allows reimbursement for qualifying circumstance codes denoting additional complexity levels or a patient of 'extreme age'; notes no reimbursement for modifiers 23 and 47.

2020-11-06review_approved

Review approved and effective: minor administrative updates and added anesthesia modifier grid.

2017-01-03review_approved

Review approved and effective: policy language updated.

2013-11-01initial_approval

Initial approval and effective date of the policy.