CurrentAnthemPolicy ABCBSRP-0124-21

Professional Anesthesia Services

Defines Anthem Medicare Advantage reimbursement rules for professional anesthesia services including time reporting, modifiers, multiple-procedure calculation, obstetrical anesthesia, reimbursable services provided with anesthesia, and nonreimbursable items. Applies to participating providers and facilities unless superseded by contracts or CMS/state mandates.

Policy Summary

PayerAnthem

PolicyProfessional Anesthesia Services

Policy CodePolicy ABCBSRP-0124-21

Change TypeMinor administrative updates (biennial review)

Effective DateNov 6, 2020

Next Review Date

Key ActionProviders must report anesthesia services in minutes; claims submitted with an indicator other than minutes may be rejected or denied.

SourceLink

POLICY UPDATE CHANGES

Minor administrative updates to policy body and added anesthesia modifier grid.

300Obstetrical epidural time limit (minutes)

100%Reimbursement for AA and QZ modifiers

50%Reimbursement for QK/QX/QY modifiers

Not reimbursedAnesthesia by operating surgeon (modifier 47)

Anthem Medicare Advantage provides reimbursement guidance for professional anesthesia services that applies to participating providers and facilities and aligns reimbursement formulas, time increments, and modifier usage with CMS guidelines. These policies are intended to assist accurate claims submission and require use of industry-standard CPT/HCPCS/revenue codes supported by the medical record; services must meet authorization and medical necessity rules. Anthem Medicare Advantage reimbursement policies may be superseded by provider, state, federal, or CMS contracts and requirements and system/contract variations may affect claims processing.

This policy scope covers time reporting in minutes, modifier requirements, multiple-procedure calculations, obstetrical neuraxial epidural limits, separately reimbursable services provided with anesthesia, and items not reimbursed. Providers should note that failure to follow coding/billing or documentation requirements (for example, time reporting, modifier placement, and start/stop times) may result in claim rejection, denial, or recovery of payment.

Policy dates & scope

Effective date2020-11-06

Last review2020-11-06

Next review

Policy numberABCBSRP-0124-21

ScopeDefines Anthem Medicare Advantage reimbursement rules for professional anesthesia services including time reporting, modifiers, multiple-procedure calculation, obstetrical anesthesia, reimbursable services provided with anesthesia, and nonreimbursable items. Applies to participating providers and facilities unless superseded by contracts or CMS/state mandates.

General Reimbursement Requirements

Anesthesia professional services are reimbursed when the following billing and documentation requirements are met:

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Multiple Anesthesia Procedures

Reimbursement when multiple procedures are performed during anesthesia:

Multiple Anesthesia Procedures: Reimbursement is based on the anesthesia procedure with the highest base unit value and the overall anesthesia time for all procedures

When multiple procedures occur during anesthesia, reimbursement uses highest base units plus overall time

Nonreimbursable Anesthesia Services

Anthem does not reimburse the following anesthesia-related services:

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Coding, Modifiers, and Reimbursement Rules

Providers must report anesthesia services in minutes; claims submitted with an indicator other than minutes may be rejected or denied. Anesthesia start and stop times must be documented in the members medical record, with time beginning when the provider prepares the member for administration of anesthesia and ending when the provider is no longer in personal and continuous attendance. Modifiers that identify who performed the anesthesia service (for example AA, QK, QX, QY, QZ, AD, 23, 47) must be billed in the primary modifier field to receive appropriate reimbursement; claims submitted without the appropriate primary modifier may be denied.

Anesthesia Modifiers and Reimbursement Rulesmixed

AA	Anesthesia services personally performed by the anesthesiologist; Reimbursed at 100% of applicable fee schedule or contracted/negotiated rate
AD	Medical supervision by a physician: more than four concurrent anesthesia procedures; Reimbursed at 100% of applicable fee schedule or contracted/negotiated rate for up to three base units for anesthesiologists
QK	Medical direction of two, three, or four concurrent anesthesia procedures involving qualified individuals; Reimbursed at 50% of allowance
QX	Qualified nonphysician anesthetist with medical direction by a physician; Reimbursed at 50% of allowance
QY	Anesthesiologist medically directs one CRNA; Reimbursed at 50% of allowance
QZ	CRNA without medical direction by a physician; Reimbursed at 100% of applicable fee schedule or contracted/negotiated amount
23	Denotes a procedure that must be done under general anesthesia due to unusual circumstances although normally done under local or no anesthesia; Reimbursed at 100% of applicable fee schedule or contracted/negotiated rate of the procedure; does not increase or decrease reimbursement
47	Denotes regional or general anesthesia services provided by the surgeon performing the medical procedure; Anthem does not allow reimbursement of anesthesia services by the provider performing the medical procedure (other than obstetrical)

Numeric thresholds & reimbursement highlights

Obstetrical neuraxial epidural time limitReimbursed up to 300 minutes; additional documentation required for time > 300 minutes

Anesthesia time reporting incrementMinutes — time units are 15-minute increments; each 15-minute increment constitutes one time unit

AA / QZ reimbursementReimbursed at 100% of applicable fee schedule or contracted/negotiated rate

QK / QX / QY reimbursementReimbursed at 50% of allowance (50% of applicable fee schedule or contracted/negotiated amount)

Modifier 47 (anesthesia by operating surgeon)Not reimbursed (no additional reimbursement allowed except for obstetrical delivering physician)

Billing & Documentation Actions

Billing Rule

Report anesthesia services in minutes

Providers must report anesthesia services in minutes. Claims submitted with an indicator other than minutes may be rejected or denied.

Claims with an indicator other than minutes may be rejected or denied.

Documentation Required

Document start/stop times and continuous attendance

Start and stop times must be documented in the member's medical record. Anesthesia 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 Rule

Append appropriate anesthesia modifiers

Modifiers identifying who performed the anesthesia service must be billed in the primary modifier field to receive appropriate reimbursement. Claims submitted for anesthesiology services without the appropriate modifier will be denied.

Affected modifiers: AA, AD, QK, QX, QY, QZ, 23, 47
Claims without the appropriate modifier will be denied.

Documentation Required

Additional documentation for obstetrical time >300 minutes

For obstetrical neuraxial epidural anesthesia, providers must submit additional documentation upon dispute for consideration of reimbursement for time in excess of 300 minutes.

Billing Rule

Multiple procedures reimbursement calculation

When multiple procedures occur during anesthesia, reimbursement is based on the anesthesia procedure with the highest base unit value combined with the overall anesthesia time for all procedures.

OpenPayer

Professional Anesthesia Services

Policy Overview

General Reimbursement Requirements

Coding, Modifiers, and Reimbursement Rules

Billing & Documentation Actions

Definitions

Policy Revision History