Defines Anthem Medicare Advantage reimbursement rules for professional anesthesia services including time reporting, modifiers, multiple procedures, qualifying circumstances, oral surgery, included/excluded services in global anesthesia reimbursement, postoperative pain management, and related coding/billing requirements.
Policy Summary
PayerAnthem
PolicyProfessional Anesthesia Services (MA PPO)
Policy CodePolicy N/A
Change TypeClarified; Revised (non-material)
Effective Date11/25/2020
Next Review DateN/A
Key ActionProviders must report anesthesia services in one-minute increments, document start and stop times in the medical record, and submit minutes to be converted to time units per policy.
Updated language and removed the word 'up' from the Time section to align with configuration.
Biennial review approved; minor administrative updates and update to definition section.
1Primary guidance document
MultipleReferenced CPT/Modifier groups
0Excluded medications reimbursed separately
Policy overview
Anthem Medicare Advantage reimburses professional anesthesia services using the American Society of Anesthesiologists (ASA) anesthesia formula as the primary basis, with reimbursement calculated from base units (BU), reported time in minutes converted to time units by dividing minutes reported by 15 and rounded to the nearest tenth, and a conversion factor, and requires industry-standard CPT/HCPCS codes and supporting documentation on the claim and in the medical record.
Modifiers identifying who performed the anesthesia must be appended to the anesthesia procedure code in the primary modifier field for appropriate reimbursement; informational MAC modifiers (G8, G9, QS) may be reported in a subsequent modifier field. Claims without appropriate modifiers or with an indicator other than minutes for time may be rejected or denied.
Anthem aligns with NCCI guidance for included/incidental services: many monitoring and peri-anesthesia services (for example, echocardiography when incidental, EEG, inhalation treatments, noninvasive monitoring, airway placement, IV placement and routine medication administration) are considered included in the global anesthesia reimbursement and are not eligible for separate reimbursement; certain procedures (e.g., distinct TEE 93312-93317 with appropriate modifier, Swan-Ganz, invasive lines) and postoperative nerve/epidural injections (62320-62327, 64413-64425, 64445-64450) may be eligible separately when billed with required modifiers and documentation.
When multiple surgical procedures occur, only the anesthesia code for the most complex service is reported for base units; add-on anesthesia codes 01953, 01968, and 01969 are eligible separately. Anthem may allow a second separate anesthesia reimbursement only when records show a distinct subsequent operative session separated by more than one hour.
Field avoidance or procedures around the head, neck, or shoulder girdle, or procedures requiring positions other than supine or lithotomy, are assigned a minimum base value of 5 regardless of a lower published base unit; unusual positioning is not eligible for additional reimbursement even if reported with modifier 22.
Required documentation and claim submission expectations: report anesthesia time in one-minute increments, document start and stop times in the member's medical record, submit minutes (not other indicators) so time units can be calculated per policy, use appropriate CPT/HCPCS codes and modifiers, and ensure billed codes are fully supported in the medical record to avoid denial, recoupment, or adjustment.
Policy metadata and thresholds
PayerAnthem
PolicyProfessional Anesthesia Services (MA PPO)
Policy NumberN/A
Effective Date2020-11-25
Last Review2021-09-22
Next Review
Key threshold: Time unit conversionminutes reported ÷ 15, rounded to nearest tenth
Coverage criteria and clinical rules
Reporting Time for Anesthesia
Anesthesia time reporting and calculation requirements:
ALL of the following
Report minutes: Providers must report anesthesia services in one-minute increments and note in the units field.
Conversion to time units: To calculate reimbursement for time, the number of minutes reported is divided by 15 (minutes) and rounded to the nearest tenth to provide a unit of measure.minutes reported ÷ 15, rounded to nearest tenth
Time indicator: Anesthesia claims submitted with an indicator other than minutes may be rejected or denied.
Start/stop documentation: Start and stop times must be documented in the member's medical record.
Definition of anesthesia time: Anesthesia time starts with the 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 of time if there is an interruption in anesthesia, as long as the time counted is that in which continuous anesthesia services are provided.
Anesthesia Modifiers and Payment Caps
Modifier usage and reimbursement interactions:
ALL of the following
Modifier purpose: Anesthesia modifiers are appended to the applicable procedure code to indicate the specific anesthesia service or who performed the service.
Primary modifier field: Modifiers identifying who performed the anesthesia must be billed in the primary modifier field to receive appropriate reimbursement.
MAC modifiers: Modifiers G8, G9, or QS may be reported in a subsequent modifier field when the service rendered is monitored anesthesia care (MAC).
These modifiers are informational and allowed in a subsequent field for MAC.
Missing modifier denial:
Multiple Procedures
Rules when anesthesia is provided for multiple surgical procedures:
ALL of the following
Primary only: When anesthesia services are provided for multiple surgical procedures, only the anesthesia procedure code for the most complex service should be reported.
Base units for primary: Base units are only used for the primary procedure and not for any secondary procedures.
Denial of lesser: If two separate anesthesia codes are reported, the procedure with the lesser charge will be denied.
Add-on exceptions: Exception: Add-on codes 01953, 01968, or 01969 are eligible for separate reimbursement in addition to the code for the primary procedure.
Field Avoidance and Unusual Positioning
Minimum base unit adjustment for field avoidance/unusual positioning:
ALL of the following
Minimum base value: Any procedure around the head, neck, or shoulder girdle requiring field avoidance, or any procedure requiring a position other than supine or lithotomy, is allowed a minimum base value of 5 regardless of any lesser base value assigned to such procedure.minimum base value of 5
Modifier 22 ineligible: Unusual positioning is not eligible for additional reimbursement even when reported with modifier 22.
Qualifying Circumstances (Additional Reimbursement Codes)
CPT qualifying circumstance codes reportable in addition to anesthesia:
ONE of
99100: Anesthesia for patient of extreme age, younger than one 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.
CPT 99140 is eligible for separate reimbursement for emergency services but may be denied for unscheduled routine obstetric delivery with specified diagnoses.
Mutually exclusive determination:
Anesthesia for Oral Surgery
Billing rules when oral surgeon also provides anesthesia:
ALL of the following
CDT anesthesia codes: Anesthesia for covered oral surgical procedures may be reported with CDT-based anesthesia codes D9210-D9248 for the anesthesia service.
Modifier 47 required: An oral surgeon reporting services with a CPT procedure and also providing an anesthesia service must append modifier 47.
No additional reimbursement for CPT+47: There is no additional reimbursement for the CPT code appended with modifier 47; only the covered oral surgery procedure is eligible for reimbursement.
Services Included/Excluded in Global Reimbursement
Services considered included in the global anesthesia reimbursement and exceptions:
ALL of the following
Global inclusion statement: Global reimbursement includes all procedures integral to the successful administration of anesthesia from initial pre-anesthesia evaluation through the time the provider is no longer in personal attendance.
Included services (not eligible for separate reimbursement)
EEG: Electroencephalogram (EEG)
TEE: Echocardiography
Monitoring:
Medication Reporting in Facility Setting
Policy on separate reimbursement for medications reported by professional provider in facility:
ALL of the following
Medication not eligible: When an anesthesiologist, non-physician anesthesia provider, anesthesia group or other 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 included: Anthem considers provision of any medication, including Propofol, to be included under the facility's charge.
Services Eligible for Separate Reimbursement
Specific procedures that may be reimbursed separately in conjunction with anesthesia:
ANY of the following
Discrete separately reimbursable procedures: Swan-Ganz catheter insertion; Central venous pressure line insertion; Intra-arterial lines; Transesophageal echocardiography (TEE).
TEE separate reimbursement requirements: If a TEE (CPT codes 93312-93317) is performed as a distinct and independent procedure from the anesthesia service, then the appropriate modifier must be appended to the TEE code to be eligible for separate reimbursement.
TEE incidental codes: If TEE services are for monitoring purposes (e.g., CPT code 93318) or guidance of transcatheter intracardiac or great vessel structural interventions (e.g., CPT code 93355), Anthem will follow NCCI edit logic and consider the codes incidental and a bypass modifier will not override.
Postoperative Pain Management
Rules for reimbursement of postoperative pain management services provided by an anesthesiologist:
ALL of the following
Eligible codes: Postoperative pain management services such as an injection or catheter insertion into the epidural space or major nerve are eligible for separate reimbursement; time units are not applicable. Applies to codes/ranges: 62320-62327, 64413-64425, and 64445-64450.
Bilateral reporting: When performed bilaterally, the unilateral code must be reported once with modifier 50 using the applicable base value for the unilateral code; the pain management code will be considered one surgical service and eligible for reimbursement equal to 150% of the allowance for the code.150% allowance when modifier 50 used
Separate from primary anesthesia: An 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; the appropriate modifier must be appended to indicate a distinct procedural service.
Code lists and modifiers
Qualifying circumstance CPT codes (eligible in addition to anesthesia procedure)CPTCovered
99100
Anesthesia for patient of extreme age, younger than one year and older than 70
99116
Anesthesia complicated by utilization of the total body hypothermia
99135
Anesthesia complicated by utilization of controlled hypotension
Daily hospital management of epidural or subarachnoid continuous drug administration
Oral surgery CDT anesthesia codes (covered)mixedCovered
D9210-D9248
CDT-based anesthesia codes for oral surgical procedures
TEE and related echocardiography codes (mixed)CPT
93312-93317
TEE codes (eligible separately if distinct and independent; modifier required)
93318
TEE for monitoring purposes (considered incidental per NCCI edit logic)
93355
TEE guidance of transcatheter intracardiac or great vessel structural intervention (considered incidental per NCCI edit logic)
Modifiers referenced (neutral)Modifier
G8
MAC monitoring modifier (informational; may be reported in subsequent modifier field)
G9
MAC monitoring modifier (informational)
QS
MAC monitoring modifier (informational)
QK
Anesthesia service: medically directed CRNA
QX
Anesthesia service: CRNA with medical direction
QY
Anesthesia service: medical direction of one CRNA by an anesthesiologist
47
Modifier 47: Anesthesia by surgeon
50
Modifier 50: Bilateral procedure
Billing, documentation, and denial risk — actions for providers
Documentation Required
Report anesthesia time in minutes and document start/stop times
Report anesthesia time in one-minute increments in the units field. Start and stop times must be documented in the member's medical record. Minutes reported are converted to time units by dividing minutes by 15 and rounding to the nearest tenth.
Report minutes (one-minute increments) in units field
Conversion: minutes ÷ 15, rounded to nearest tenth
Document start and stop times in the medical record
Billing Rule
Use appropriate anesthesia modifiers and primary modifier position
Append modifiers that identify who performed the anesthesia to the applicable procedure code. Modifiers identifying the performer must be billed in the primary modifier field to receive appropriate reimbursement. For monitored anesthesia care (MAC), modifiers G8, G9, or QS may be reported in a subsequent modifier field.
Applicable modifiers: G8, G9, QS, QK, QX, QY
Performer-identifying modifiers must be in the primary modifier field
G8/G9/QS may be used in a subsequent modifier field for MAC
Billing Rule
Multiple procedure reporting
When anesthesia is provided for multiple surgical procedures, report only the anesthesia code for the most complex service; base units apply only to the primary procedure and lesser anesthesia codes will be denied. Exceptions: add-on anesthesia codes 01953, 01968, and 01969 are eligible for separate reimbursement. If documentation shows a separate subsequent operative session with more than an hour separation, the second anesthesia service may be eligible separately.
Report only most complex anesthesia procedure code (primary)
Separate session exception: >1 hour separation with documentation
Billing Rule
Medication billing in facility
Medications provided by an anesthesiologist or other professional provider in a facility setting are considered included in the facility's charge and are not eligible for separate reimbursement. This includes Propofol and medications reported with unclassified or unspecified drug codes.
Medications (including Propofol) reported by professionals in facility = included in facility charge
Not eligible for separate reimbursement even if billed with unclassified/unspecified drug codes
Billing Rule
TEE separate reimbursement requirements
TEE codes in the range 93312–93317 may be eligible for separate reimbursement only when performed as a distinct and independent procedure and the appropriate modifier is appended. CPT codes 93318 (monitoring) and 93355 (guidance of transcatheter interventions) are considered incidental per NCCI edit logic and will not be reimbursed separately; a bypass modifier will not override the incidental determination.
TEE codes eligible for distinct reimbursement: 93312-93317 (modifier required)
Incidental per NCCI (not separately reimbursed): 93318, 93355
A bypass/59-type modifier will not override NCCI incidental logic for 93318/93355
Denial Risk
Claims may be denied for incorrect time indicator or missing modifiers
Claims submitted with an indicator other than minutes or without appropriate anesthesia modifiers may be rejected or denied. Ensure time is reported in minutes and applicable modifiers are appended in the required fields to reduce denial risk.
Incorrect time indicator (not minutes) can lead to claim rejection/denial
Missing or improperly positioned performer modifiers can lead to denial
Billing Rule
Postoperative pain management coding rules
Postoperative pain management services such as injections or catheter insertions into the epidural space or major nerve (CPT ranges 62320–62327, 64413–64425, 64445–64450) are eligible for separate reimbursement; time units do not apply. Bilateral procedures: report the unilateral code once with modifier 50 and reimbursement is 150% of the allowance. Daily hospital management code 01996 is eligible once per post-op date of service but when billed with an injection code (e.g., 62320–62327) only the injection is eligible; modifiers will not override that edit. When QK, QX, or QY is appended to an applicable spinal/nerve injection code, reimbursement is reduced to 50%. Anthem will deny 01996 when billed with a physical status modifier or qualifying circumstance codes.
QK/QX/QY on applicable injection codes reduces reimbursement to 50%
01996 denied when billed with physical status modifier or qualifying circumstance codes
Key definitions
Definitions
Base Units (BU)Base Units are assigned to a specific anesthesia CPT code and are derived from the ASA Anesthesia Relative Value Guide (RVG).
Time Units (TU)An increment of fifteen (15) minutes where each 15-minute increment constitutes one (1) time unit. Providers must report anesthesia services in one-minute increments; minutes are converted to time units for reimbursement (minutes ÷ 15, rounded to nearest tenth).
Conversion Factor (CF)A single unit rate used in the calculation for anesthesia reimbursement.
General/Regional/LocalGeneral: anesthesia affecting the entire body with loss of consciousness. Regional: loss of sensation of a particular region. Local: loss of sensation in a limited superficial area.
Policy revision timeline
11/25/2020revised
Biennial review approved; minor administrative updates and update to definition section.
09/22/2021clarifiedLatest
Review update: Updated language and removed the word 'up' from the Time section to align with configuration (non-material wording change).
Policy Summary
PayerAnthem
PolicyProfessional Anesthesia Services (MA PPO)
Policy CodePolicy N/A
Change TypeClarified; Revised (non-material)
Effective Date11/25/2020
Next Review DateN/A
Key ActionProviders must report anesthesia services in one-minute increments, document start and stop times in the medical record, and submit minutes to be converted to time units per policy.
Claims submitted for anesthesiology services without the appropriate modifier will be denied.
Payment cap when physician + non-physician: The total reimbursement for anesthesia services provided by a physician/anesthesiologist and a non-physician anesthesia provider will not exceed 100% of the eligible amount that would be allowed had the anesthesia service been provided by only the physician/anesthesiologist.
Separate subsequent session: If Anthem can determine from the anesthesia record that a separate subsequent operative session took place with more than an hour separation from the initial anesthesia, the second subsequent anesthesia service may be considered eligible for separate reimbursement.> 1 hour separation
Anthem will determine when there may be a mutually exclusive relationship with the reported base anesthesia code.
Placement and interpretation of any non-invasive monitoring (ECG, temperature, blood pressure, pulse oximetry, carbon dioxide, expired gas determination by infrared analyzer/capnography and mass spectrometry, and vital capacity)
Lines: Placement of endotracheal and naso-gastric tubes; placement of peripheral intravenous lines and administration of fluids, anesthetic, or other medications through a needle or tube inserted into a vein; venipuncture and transfusion
E/M windows: One-day preoperative E/M services and 10-day postoperative E/M services are considered included in the global reimbursement (10-day postoperative period applies to the anesthesiologist or other qualified professional who performed the general anesthesia or other providers in the same anesthesia provider group).
Nerve block exception: Nerve block injections for pain management will be eligible for separate reimbursement.
01996 interaction: Daily hospital management of epidural or subarachnoid continuous drug administration (CPT code 01996) for postoperative pain management is eligible once per date of service following the surgery date; when 01996 is reported with an anesthetic injection code (e.g., 62320-62327), only the injection code is eligible for reimbursement and modifiers will not override edits.once per date of service; 01996 denied when billed with injection code
QK/QX/QY reduction: When modifier QK, QX, or QY is appended to an applicable spinal/nerve injection code, the reimbursement percentage of 50% will apply.50% reimbursement when QK/QX/QY appended
Denial with physical status or qualifying circumstance: Anthem will deny the daily hospital management of epidural or subarachnoid continuous drug administration procedure code when billed with a physical status modifier or qualifying circumstance procedure codes.