CurrentAnthemPolicy N/A

Professional Anesthesia Services

Defines Anthem (AMH Health) reimbursement rules for professional anesthesia services including time reporting, allowance calculation per CMS, modifier usage, multiple procedure handling, obstetrical neuraxial epidural limits, reimbursable concurrent services, and non-reimbursable items.

Policy Summary

PayerAnthem (AMH Health)

PolicyProfessional Anesthesia Services

Policy CodePolicy N/A

Change TypeAdministrative updates; modifier table added

Effective DateJan 1, 2020

Next Review DateN/A

Key ActionReport anesthesia services in minutes, document start/stop times, and bill the appropriate anesthesia performer modifier in the primary modifier field to avoid denials.

SourceLink

POLICY UPDATE CHANGES

Biennial review approved 11/06/20: minor administrative updates; added anesthesia modifier grid.

Initial approval and effective date 01/01/20.

6Services separately reimbursable

7Modifiers documented

300Obstetrical epidural time limit (minutes)

Policy overview

AMH (Anthem) reimburses professional anesthesia services following a CMS-based allowance and reimbursement formula. The policy requires providers to report anesthesia time in minutes with start and stop times documented in the medical record (time starts with preparation for administration and stops when the provider is no longer in personal and continuous attendance). Modifiers identifying who performed the service must be billed in the primary modifier field, and claims without the appropriate modifier or with incorrect coding/documentation may be denied, rejected, or subject to recoupment. Reimbursement for multiple procedures is based on the procedure with the highest base unit value and the total anesthesia time. Obstetrical neuraxial epidural analgesia provided in conjunction with labor and delivery is reimbursed for up to 300 minutes (documentation required to consider time beyond 300 minutes). Certain services (for example, Swan-Ganz catheter insertion, central venous pressure line insertion, intra-arterial lines, emergency intubation when provided with the anesthesia procedure, critical care visits, and transesophageal echocardiography) may be reimbursed separately, while listed non-reimbursable items (including anesthesia by the provider performing the basic procedure except delivering physicians for continuous epidural analgesia, local anesthesia incidental to the procedure, standby anesthesia, consultations tied to the preoperative assessment, patient status/qualifying circumstance modifiers, and services for noncovered procedures) are not reimbursed. Contract-, state-, federal- or CMS-level mandates or provider agreements may supersede this policy.

Coverage criteria and limits

General reimbursement and reporting requirements

Anesthesia services are reimbursed when billed per CMS-based allowance and meeting documentation and coding rules:

ALL of the following

Reimbursement based on the reimbursement formula for the allowance and time increments in accordance with CMS.
Providers must report anesthesia services 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 starts with preparation for administration and stops when provider is no longer in personal and continuous attendance.
Anesthesia modifiers identifying who performed the 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.

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Multiple anesthesia procedures

When multiple procedures occur during anesthesia:

ALL of the following

Reimbursement is based on the anesthesia procedure with the highest base unit value and the overall time of all anesthesia procedures.

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Obstetrical neuraxial epidural anesthesia

Coverage and limits for epidural analgesia in labor & delivery:

ALL of the following

Reimbursed for neuraxial epidural anesthesia services provided in conjunction with labor and delivery for up to 300 minutes by either the delivering physician or a qualified provider other than the delivering physician, based on the time the provider is physically present with the member.<= 300 minutes
Providers must submit additional documentation upon dispute for consideration of reimbursement of time in excess of 300 minutes.
Providers must submit additional documentation upon dispute for consideration of reimbursement of time in excess of 300 minutes.
Reimbursement basis
- Delivering physician: For the delivering physician: based on a flat rate or fee schedule using the surgical CPT pain management codes for epidural analgesia.

Services eligible for separate reimbursement

The following services may be reimbursed separately (no reporting of time; based on fee schedule or contracted rate):

ALL of the following

Swan-Ganz catheter insertion
Central venous pressure line insertion
Intra-arterial lines
Emergency intubation (must be provided in conjunction with the anesthesia procedure to be considered for reimbursement)
Critical care visits

Non-reimbursable anesthesia services

AMH Health does not reimburse the following anesthesia-related services:

ALL of the following

Use of patient status modifiers or qualifying circumstances codes denoting additional complexity levels.
Anesthesia consultations on the same date as surgery or the day prior to surgery, if part of the preoperative assessment.
Anesthesia services performed for noncovered procedures, including services considered not medically necessary, experimental and/or investigational.
Anesthesia services by the provider performing the basic procedure, except for a delivering physician providing continuous epidural analgesia.
Local anesthesia considered incidental to the surgical procedure.

Modifiers and coding guidance

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 the 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 the applicable fee schedule or contracted/negotiated amount.
QY	Anesthesiologist medically directs one CRNA. Reimbursed at 50% of the applicable fee schedule or contracted/negotiated amount.
QZ	CRNA without medical direction by a physician. Reimbursed at 100% of the 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 the applicable fee schedule or contracted/negotiated rate of the procedure; does not increase or decrease reimbursement; substantiates billing anesthesia associated with the procedure in cases where anesthesia is not usually appropriate.
47	Denotes regional or general anesthesia services provided by the surgeon performing the medical procedure; AMH Health does not allow reimbursement of anesthesia services by the provider performing the medical procedure (other than obstetrical). Not appropriate to bill Modifier 47 with anesthesia services; no additional reimbursement allowed.

Billing Rule

Primary modifier field requirement

Modifiers identifying who performed the anesthesia service must be billed in the primary modifier field; claims without the appropriate modifier will be denied.

Billing Rule

Report anesthesia time in minutes

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

Documentation Required

Start/stop time documentation

Start and stop times must be documented in the medical record (time starts with preparation for administration and stops when provider no longer in personal and continuous attendance).

Billing and documentation actions

Billing Rule

Multiple procedures allowance

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

Documentation Required

Obstetrical epidural documentation for >300 minutes

Submit additional documentation upon dispute for consideration of reimbursement for time in excess of 300 minutes for neuraxial epidural labor analgesia.

Failure to follow the policy's coding, documentation, and modifier rules (including reporting time in minutes and billing the appropriate anesthesia modifier in the primary modifier field) may result in claim denial, rejection, or recovery/recoupment of payment; contract-level, state/federal, or CMS mandates or provider agreements may override or supersede this policy.

OpenPayer

Professional Anesthesia Services

Policy overview

Coverage criteria and limits

Modifiers and coding guidance

Billing and documentation actions

Key definitions

Document revision history