Anthem Anesthesia Policy Update — Coverage Rules

Policy overview

Anthem Medicare Advantage anesthesia reimbursement policy aligns with the American Society of Anesthesiologists (ASA) anesthesia formula and follows NCCI coding guidance and Anthem coding logic. It governs billing and reimbursement for professional anesthesia services including the required use and placement of anesthesia modifiers, one-minute time reporting with conversion to time units (minutes / 15, rounded to the nearest tenth), rules for multiple procedures and selection of the primary anesthesia code, qualifying circumstance codes, and distinctions between services included in global anesthesia reimbursement and those eligible for separate payment (including specific pain management codes and limitations). Effective date: 11/25/2020; Last approval/review date: 09/22/2021; Status: CURRENT.

Coverage and reporting criteria

Time reporting and unit calculation

Anesthesia time reporting and time unit calculation requirements:

Providers must report anesthesia services in one-minute increments and note in the units field.

To calculate reimbursement for time, the number of minutes reported is divided by 15 and rounded to the nearest tenth to provide a unit of measure.Minutes reported / 15, rounded to nearest tenth

Anesthesia 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 the preparation of the member for administration of anesthesia and stops when the anesthesia provider is no longer in personal attendance.

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 pay percent modifiers

Modifier reporting and reimbursement constraints:

Anesthesia modifiers are appended to the applicable procedure code to indicate the specific anesthesia service or who performed the service.

Modifiers identifying who performed the anesthesia must be billed in the primary modifier field to receive appropriate reimbursement.

Modifiers G8, G9, or QS may be reported in a subsequent modifier field when the service rendered is monitored anesthesia care (MAC).

Claims submitted for anesthesiology services without the appropriate modifier will be denied.

Total reimbursement for anesthesia services provided by a physician 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.

Multiple procedures

Reporting when multiple surgical procedures occur:

When anesthesia services are provided for multiple surgical procedures, only the anesthesia procedure code for the most complex service should be reported.

Base units are only used for the primary procedure and not for any secondary procedures.

If two separate anesthesia codes are reported, the procedure with the lesser charge will be denied.

Exception: Add-on codes 01953, 01968, and 01969 are eligible for separate reimbursement in addition to the primary procedure.

Field avoidance and unusual positioning

Minimum base value and modifier 22 guidance for field avoidance and unusual positioning:

Any procedure around the head, neck, or shoulder girdle requiring field avoidance, or any procedure requiring a position other than supine or lithotomy, has a minimum base value of 5 regardless of any lesser base value assigned to such procedure.Base value = 5

Field avoidance is not eligible for additional reimbursement even when reported with modifier 22.

Qualifying circumstances

Qualifying circumstance CPT codes reportable in addition to the anesthesia procedure:

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.

99140 is eligible for separate reimbursement for emergency services; not eligible separately when reported for an unscheduled routine obstetric delivery with specified diagnosis codes.

Anthem will determine when there may be a mutually exclusive relationship with the reported base anesthesia code.

Anesthesia for oral surgery

Reimbursement interaction between CPT anesthesia codes and CDT dental anesthesia codes:

Allows reimbursement for anesthesia for covered oral surgical procedures reported with CDT anesthesia codes D9210-D9248.

CPT anesthesia codes 00170-00176 will not be eligible for reimbursement when reported with CDT procedures.

CDT anesthesia codes D9210-D9248 will not be eligible for separate reimbursement when reported with CPT procedure codes.

If an oral surgeon reports a CPT procedure and also provides an anesthesia service, they must append modifier 47; there is no additional reimbursement — only the covered oral surgery procedure is eligible for reimbursement.

Services included/excluded in global anesthesia reimbursement

Services considered part of global anesthesia reimbursement and exceptions:

Global reimbursement includes all procedures integral to administration of anesthesia from initial pre-anesthesia evaluation through time when the anesthesiologist is no longer in personal attendance.

Included and not eligible for separate reimbursement: daily hospital management of patient-controlled analgesia, echocardiography, EEG, inhalation treatments, laryngoscopy and bronchoscopy, placement and interpretation of non-invasive monitoring (ECG, temperature, blood pressure, pulse oximetry, capnography, mass spectrometry, vital capacity), placement of endotracheal/nasogastric tubes, placement of peripheral IV lines and administration of fluids/anesthetic/medications through IV, venipuncture and transfusion.

One-day preoperative E/M services and 10-day postoperative E/M services are considered included in the global reimbursement for general anesthesia (10-day postoperative period includes follow-up and postoperative pain management E/M).

Nerve block injections for pain management are eligible for separate reimbursement.

Postoperative pain management

Separate reimbursement rules for postoperative pain management services:

Postoperative pain management services by an anesthesiologist, such as injection or catheter insertion into the epidural space or major nerve, are eligible for separate reimbursement and time units are not applicable.Applies to codes/ranges 62320-62327, 64413-64425, 64445-64450

When postoperative pain management services are performed bilaterally, report the unilateral code once with modifier 50; the pain management code will be considered one surgical service and reimbursed equal to 150% of the allowance for the code.Reimbursed at 150% when bilateral via modifier 50

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 when the appropriate modifier is appended to indicate a distinct procedural service.

Code lists and coding guidance

Anesthesia qualifying circumstance codes (report in addition to base anesthesia)CPTCovered

99100	Anesthesia for patient of extreme age
99116	Anesthesia complicated by utilization of the total body hypothermia
99135	Anesthesia complicated by utilization of controlled hypotension
99140	Anesthesia complicated by emergency conditions

Anesthesia add-on codes eligible for separate reimbursementCPTCovered

01953	Add-on anesthesia code (eligible separately)
01968	Add-on anesthesia code (eligible separately)
01969	Add-on anesthesia code (eligible separately)

Oral/dental anesthesia CDT codesNDC|mixedCovered

D9210-D9248

CDT-based anesthesia codes for oral surgical procedures; allowed when reported alone

Pain management procedure codes eligible separatelyCPTCovered

62320-62327	Epidural/nerve injection codes
64413-64425	Nerve block injection codes
64445-64450	Peripheral nerve block codes
01996	Daily hospital management of epidural/subarachnoid continuous drug administration

TEE and monitoring CPT codes (separate reimbursement conditional)CPT

93312-93317	TEE codes eligible for separate reimbursement if distinct and independent; appropriate modifier required
93318	TEE monitoring code; considered incidental to anesthesia per NCCI edits
93355	TEE for guidance of transcatheter intracardiac/great vessel interventions; considered incidental per NCCI edits

Anesthesia CPT codes not eligible with CDT when both reportedCPTNot Covered

00170-00176

Anesthesia for intraoral procedures; not eligible when reported with CDT procedures

Billing, documentation, and denial risks

Billing Rule

Report anesthesia time in minutes and units calculation

Report anesthesia services in one-minute increments; minutes divided by 15 and rounded to nearest tenth to determine time units. Start/stop times must be documented in the medical record.

Document start and stop times in the member's medical record.
Report minutes; reimbursement time units = minutes / 15, rounded to nearest tenth.

Billing Rule

Append appropriate anesthesia modifiers in primary modifier field

Modifiers identifying who performed the anesthesia (e.g., AA, AD, QK/QX/QY/QZ) must be billed in the primary modifier field; claims without appropriate modifiers will be denied.

Examples: AA, AD, QK, QX, QY, QZ

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 and minutes are used to calculate time units.

Conversion Factor (CF)A single unit rate used in the calculation for anesthesia reimbursement.

Time unit threshold15 minutes = 1 time unit (minutes reported divided by 15 and rounded to the nearest tenth).

Operational thresholds

Thresholds

Time unit conversionMinutes reported / 15, rounded to nearest tenth (report minutes in one-minute increments; start/stop times documented).

Field avoidance minimum base valueAny procedure around the head, neck, or shoulder girdle requiring field avoidance, or requiring a position other than supine or lithotomy, has a minimum base value of 5 regardless of any lesser base value assigned to the procedure.

Policy revision history

02/07/2017revised

Added 2017 codes for spinal injections (62320-62327) under Pain Management; deleted duplicate routine maternity diagnoses; no change to editing concept.

11/16/2018revised

Biennial review: updated policy language in all sections and created market exemption table.

06/01/2019administrative

Updated policy template and definitions; retained modifier table and ICD-10 table.

OpenPayer

Professional Anesthesia Services (MA PPO)