CurrentAnthemPolicy G-07018

Professional Anesthesia Services PDF

Defines Anthem's reimbursement rules for professional anesthesia services including time reporting, modifier usage, multiple procedures, obstetrical neuraxial epidural reimbursement limits, separately reimbursable services, and nonreimbursable items. Applies to professional providers for Anthem-covered members, subject to state/CMS/provider contracts.

Policy Summary

PayerAnthem

PolicyProfessional Anesthesia Services PDF

Policy CodePolicy G-07018

Change TypeTemplate updates; administrative revisions

Effective DateNov 6, 2020

Next Review Date

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

SourceLink

POLICY UPDATE CHANGES

Policy template updated.

Added anesthesia modifier grid and reimbursement formulas.

3Physical status modifiers with additional reimbursement (P3,P4,P5)

15Time unit increment (minutes)

300Obstetrical epidural max reimbursable time (minutes)

Policy Overview

Anthem reimburses professional anesthesia services using the CMS-based anesthesia allowance formula and time increments. Anesthesia time must be reported in minutes with documented start and stop times; claims submitted with an indicator other than minutes may be rejected or denied. Time units are based on 15-minute increments per CMS guidance.

Modifier use must follow policy and state/CMS requirements; modifiers identifying who performed the anesthesia service must be billed in the primary modifier field or claims will be denied. Anthem allows Modifier 99 and permits additional reimbursement for physical status modifiers P3, P4, and P5 (P3 and P4 increase unit value by two; P5 increases unit value by four). Anthem does not allow Modifier AD or Modifier 23.

When multiple anesthesia procedures occur on the same date, reimbursement is based on the anesthesia procedure with the highest base unit value plus the overall anesthesia time across procedures. For obstetrical neuraxial epidural analgesia in labor and delivery, Anthem allows reimbursement for up to 300 minutes by either the delivering physician or a qualified provider; reimbursement for time >300 minutes requires submission of additional documentation for dispute review. Separately reimbursable services (e.g., Swan-Ganz catheter, central venous pressure line, intra-arterial lines, emergency intubation when in conjunction with anesthesia, critical care visits, transesophageal echocardiography) are paid per fee schedule or contracted rate without reporting time.

Scope: This policy defines Anthem's reimbursement rules for professional anesthesia services — including time reporting, modifier usage, multiple procedures, obstetrical neuraxial epidural limits, separately reimbursable services, and nonreimbursable items — and applies to professional providers for Anthem-covered members unless superseded by provider, state, federal, or CMS contracts.

General Reimbursement Requirements & Criteria

General Reimbursement Requirements

Anthem allows reimbursement of anesthesia services when ALL of the following are met:

ALL of the following

Service is rendered by professional provider for an Anthem covered member
Service meets authorization and medical necessity guidelines appropriate to the procedure and diagnosis and member's state of residence
Claims use industry standard compliant codes (CPT, HCPCS, revenue codes) and are supported in the medical record
Anesthesia time is reported in minutes; start and stop times are documented
Claims submitted with an indicator other than minutes may be rejected or denied
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

Modifier Rules & Allowed/Disallowed Modifiers

Modifier Requirements

Modifiers must be used appropriately; ALL of the following apply:

ALL of the following

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
Anthem allows use of Modifier 99
Physical status modifiers allowed (additional reimbursement applies per CMS default unless state requires otherwise):
- Modifier P3: patient with severe systemic disease - increases unit value by two
- Modifier P4: patient with severe systemic disease that is a constant threat to life - increases unit value by two
- Modifier P5: moribund patient not expected to survive without the operation - increases unit value by four
Anthem does not allow Modifier AD or Modifier 23
Use of AD or 23 will not be reimbursed

Modifiers explicitly allowedModifierCovered

99	Modifier 99 allowed
P3	Patient with severe systemic disease - increases unit value by two
P4	Patient with severe systemic disease that is a constant threat to life - increases unit value by two
P5	Moribund patient not expected to survive without the operation - increases unit value by four

Modifiers not allowed / nonreimbursableModifierNot Covered

AD	Modifier AD not allowed
23	Modifier 23 not allowed

Obstetrical Neuraxial Epidural Analgesia

Anthem allows reimbursement for neuraxial epidural anesthesia in labor/delivery when ALL of the following are met:

ALL of the following

Service is neuraxial epidural anesthesia provided in conjunction with labor and delivery
Reimbursement allowed 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 member300 minutes
Providers must submit additional documentation upon dispute for consideration of reimbursement of time in excess of 300 minutes
Documentation required only if reimbursement >300 minutes is requested
Reimbursement basis (one of):
- Delivering physician: based on a flat rate or fee schedule using the surgical CPT pain management codes for epidural analgesia
- Qualified provider other than delivering physician: based on the allowance calculation and inclusion of catheter insertion and anesthesia administration

Obstetrical epidural threshold

Obstetrical epidural max reimbursable time300 minutes

When documentation requiredProviders must submit additional documentation upon dispute for reimbursement >300 minutes

Applies toNeuraxial epidural anesthesia in labor/delivery by delivering physician or qualified provider

Separately Reimbursable Services

Separately Reimbursable Services with Anesthesia

Anthem allows separate reimbursement for the following services when provided in conjunction with anesthesia or as separate services:

ANY 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
Transesophageal echocardiography

Nonreimbursable Anesthesia Services

Anthem does not reimburse the following anesthesia-related services:

ANY 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 delivering physician providing continuous epidural analgesia
Local anesthesia considered incidental to the surgical procedure
Standby anesthesia services

Billing, Documentation & Denial Risks

Billing Rule

Report anesthesia time in minutes and document start/stop

Providers must report anesthesia services in minutes and document start and stop times in the medical record; 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.

Billing Rule

Bill modifiers correctly in primary modifier field

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

Documentation Required

Documentation for obstetrical epidural >300 minutes

For obstetrical neuraxial epidural analgesia, 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 anesthesia procedures are performed on the same date, reimbursement is based on the anesthesia procedure with the highest base unit value and the overall anesthesia time across all procedures.

Billing Rule

Separate reimbursement for specified procedures

Swan-Ganz catheter insertion, central venous pressure line insertion, intra-arterial lines, emergency intubation (when provided in conjunction with the anesthesia procedure), critical care visits, and transesophageal echocardiography may be billed separately and reimbursed per the applicable fee schedule or contracted/negotiated rate without reporting time.

Emergency intubation must be provided in conjunction with the anesthesia procedure to be considered for reimbursement.
Reimbursement is per fee schedule or contracted/negotiated rate and does not require reporting of time.

Denial Risk

Nonreimbursable items

Claims for nonreimbursable services—such as standby anesthesia, local anesthesia considered incidental to the surgical procedure, and anesthesia consultations that are part of the preoperative assessment—may be denied.

Definitions

Base unitThe relative value unit associated with each anesthesia procedure code as assigned by CMS.

Time unitAn increment of 15 minutes where each 15-minute increment constitutes one time unit.

Conversion factorA geographic-specific amount that varies by the locality where the anesthesia is administered.

AnesthesiaRefers to the drugs or substances that cause a loss of consciousness or sensitivity to pain.

Policy Summary

PayerAnthem

PolicyProfessional Anesthesia Services PDF

Policy CodePolicy G-07018

Change TypeTemplate updates; administrative revisions

Effective DateNov 6, 2020

Next Review Date

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

SourceLink

On This Page

OpenPayer

Professional Anesthesia Services PDF

Policy Overview

General Reimbursement Requirements & Criteria

Modifier Rules & Allowed/Disallowed Modifiers

Multiple Procedures

Obstetrical Neuraxial Epidural Analgesia

Separately Reimbursable Services

Nonreimbursable Anesthesia Services

Billing, Documentation & Denial Risks

Definitions

Policy Revision History