CurrentAnthemPolicy G-07018

Professional Anesthesia Services PDF

Defines Anthem Blue Cross and Blue Shield reimbursement rules for professional anesthesia services including time reporting, modifiers, multiple procedures, obstetrical anesthesia, billable concurrent services, and nonreimbursable items. Applies to professional providers billing anesthesia for covered members unless superseded by contracts or mandates.

Policy Summary

PayerAnthem

PolicyProfessional Anesthesia Services PDF

Policy CodePolicy G-07018

Change TypeTemplate update (06/13/2023)

Effective DateNov 6, 2020

Next Review Date

Key ActionProviders must report anesthesia services in minutes (one minute = one time unit) and document start and stop times in the medical record; claims submitted with an indicator other than minutes may be rejected or denied.

SourceLink

POLICY UPDATE CHANGES

Policy template updated; 06/13/2023 review approved (template updated).

1Minute to time unit conversion (1 minute = 1 time unit)

300Obstetrical epidural minute reimbursement cap

G-07018Policy number

Policy overview

Policy subject: Professional Anesthesia Services Reimbursement. Status: CURRENT (Policy Number G-07018; Effective 11/06/2020; Last review 06/13/2023).

High-level reimbursement basis: Anthem reimburses professional anesthesia services using the ASA reimbursement formula and time increments per ASA guidelines, with anesthesia time reported in minutes (Anthem allows one minute = one time unit). Anesthesia time begins with preparation for administration and ends when the provider is no longer in personal and continuous attendance.

Modifier and payer fallback rules: Proper use of applicable anesthesia modifiers is required; modifiers identifying who performed the anesthesia service must be billed in the primary modifier field. Claims without appropriate modifiers will be denied. Anthem does not reimburse Modifier AD and allows qualifying circumstance codes when appended with Modifier AA. Additional or reduced payment for modifiers follows state requirements, and where no state rule exists Anthem defaults to CMS guidelines.

Authorization, medical necessity, and contractual mandates: Services must meet applicable authorization and medical necessity guidelines and use industry-standard CPT/HCPCS/revenue codes fully supported in the medical record. Reimbursement policies may be superseded by provider, state, federal, or CMS contracts and/or requirements.

Policy metadata

Policy numberG-07018

Effective date2020-11-06

Last review2023-06-13

Next review

Policy subjectProfessional Anesthesia Services Reimbursement

Scope summaryDefines Anthem Blue Cross and Blue Shield reimbursement rules for professional anesthesia services including time reporting, modifiers, multiple procedures, obstetrical anesthesia, billable concurrent services, and nonreimbursable items; applies to professional providers billing anesthesia for covered members unless superseded by contracts or mandates.

General reimbursement requirements (coverage criteria)

General reimbursement requirements

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

ALL of the following

Service is provided to an Anthem covered member and is covered under the member's benefit plan
Services meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis
Providers use industry standard, compliant CPT, HCPCS, and/or revenue codes and fully support billed services in the medical record and/or office notes
Anesthesia claims are reported in minutes (one minute = one time unit); start and stop times documented in medical record
Anesthesia time definition: starts with preparation of the member for administration of anesthesia and stops when the anesthesia provider is no longer in personal and continuous attendance
Proper use of applicable modifiers; modifiers identifying who performed the anesthesia service must be billed in the primary modifier field

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Modifier requirements and billing actions

Modifier-specific rules / exclusions

Modifier application rules and exceptions:

ALL of the following

Claims for anesthesiology services submitted without the appropriate modifier will be denied
Modifier AD is not reimbursable
Qualifying circumstance procedure codes are reimbursable when appended with Modifier AA
Additional or reduced payment for modifiers is based on state requirements; absent state rule Anthem defaults to CMS guidelines

Billing Rule

Bill appropriate anesthesia modifier 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 for anesthesiology services without the appropriate modifier will be denied.

Missing or incorrect primary modifiers may cause claim denials or rejections.

Billing Rule

Do not bill Modifier AD

Modifier AD is not reimbursable and claims appended with AD will not receive reimbursement.

Billing Rule

Report anesthesia in minutes and document start/stop times

Providers must report anesthesia services in minutes (one minute = one time unit) and document start and stop times 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. Claims submitted with an indicator other than minutes may be rejected or denied.

Minute-to-time-unit conversion: 1 minute = 1 time unit (time unit = 15-minute increment)

Code groups and units

Anesthesia modifiers - prohibitedModifierNot Covered

AD	Modifier AD - not reimbursable

Anesthesia modifiers - allowed/conditionalModifierCovered

AA	Primary anesthesiologist present and medically directs care; qualifying circumstance codes allowed when appended with AA

Time reporting unitsmixed

minutes

Providers must report anesthesia services in minutes; one minute equals one time unit; time unit = 15-minute increment per definitions

Key thresholds

Minute to time unit conversion1 minute = 1 time unit

Obstetrical epidural cap<= 300 minutes reimbursed; documentation required to consider reimbursement for time >300 minutes

Special reimbursement rules

Multiple anesthesia procedures

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

Obstetrical neuraxial/epidural analgesia

ALL of the following

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

Services reimbursable in conjunction with anesthesia

Anthem allows separate reimbursement for the following when provided with or separate from anesthesia:

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

Non-reimbursable anesthesia services

Nonreimbursable anesthesia services

Anthem does not reimburse the following anesthesia-related items or services:

ANY of the following

Use of patient status modifiers
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

Denial Risk

Denial if services are noncovered or by operating surgeon

Anesthesia services for noncovered procedures, services considered not medically necessary/experimental/investigational, or anesthesia services performed by the provider performing the basic procedure (except a delivering physician providing continuous epidural analgesia) are not reimbursed and may be denied.

Key definitions

Definitions

AnesthesiaDrugs or substances that cause a loss of consciousness or sensitivity to pain.

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.

Actionable billing & documentation checklist

Documentation Required

Documentation for obstetrical anesthesia >300 minutes

Providers must submit additional documentation upon dispute to support reimbursement for obstetrical neuraxial epidural anesthesia time in excess of 300 minutes. Anthem allows reimbursement for neuraxial epidural anesthesia provided in conjunction with labor and delivery for up to 300 minutes based on the time the provider is physically present with the member.

Obstetrical epidural minute reimbursement cap: 300 minutes (documentation required to consider >300 minutes)

References

Primary references and bibliographic notes: American Society of Anesthesiologists (ASA); Centers for Medicare & Medicaid Services (CMS); Optum EncoderPro 2023; applicable State contract/State Medicaid requirements and contracts; Anthem Blue Cross and Blue Shield reimbursement policy (Policy Number G-07018).

Supporting policy materials: Anthem reimbursement policy text specifying ASA-based allowance/time increments, minute reporting rule (one minute = one time unit), modifier rules (including nonreimbursement of Modifier AD and allowance of Modifier AA for qualifying circumstance codes), and state/CMS fallback for modifier payment adjustments.

Policy revision history

06/13/2023template updateLatest

Policy template updated; review approved

11/06/2020administrative review

Review approved: minor administrative updates; added anesthesia modifier grid

10/03/2018administrative review

Review approved: policy template updated

01/03/2017administrative review

Review approved and effective 05/01/2017

07/01/2014initial approval

Initial approval and effective

Policy Summary

PayerAnthem

PolicyProfessional Anesthesia Services PDF

Policy CodePolicy G-07018

Change TypeTemplate update (06/13/2023)

Effective DateNov 6, 2020

Next Review Date

SourceLink

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