CurrentAspirus ArisePolicy AS21P0001A1

Anesthesia Policy

Aspirus Arise (Aspirus Health Plan) payment policy governing billing, reimbursement formulas, eligible providers, modifier use, and claim submission requirements for general anesthesia and monitored anesthesia care (MAC) for Medicare Advantage products.

Policy Summary

PayerAspirus Arise

PolicyAnesthesia Policy

Policy CodePolicy AS21P0001A1

Change TypeClarifications & annual reviews

Effective DateJan 1, 2021

Next Review Date

Key ActionDo not submit anesthesia base units on the claim; submit exact anesthesia minutes and ensure the medical record documents medical direction activities.

SourceLink

POLICY UPDATE CHANGES

March 17, 2025 - Annual review complete. Updates to definition and payment information sections for clarity.

April 19, 2024 - Annual review completed; intent unchanged; wording and grammar updated.

June 22, 2023 - Annual policy review; updates made to definitions, provider eligibility, and Modifiers/CPT/HCPCS/Revenue Codes sections.

January 1, 2021 - Anesthesia policy published by Aspirus Health Plan.

3Eligible Provider Types

15Common modifiers listed

15min=1Conversion factor rule

Policy summary

This Aspirus Health Plan Medicare Advantage policy (Policy Number AS21P0001A1, effective 2021-01-01, last reviewed 2025-03-17) provides billing and payment guidance for anesthesia services including general anesthesia and monitored anesthesia care (MAC). It uses ASA/ASA-adopted base units for anesthesia codes, applies the standard reimbursement formulas (allowed amount = ASA Base Units + (Total Time/15 rounded to one decimal) × conversion factor), and follows Medicare guidance for personally performed, medically directed, and medically supervised services. The policy explains modifier usage and payment impacts (for example, AA and QZ paid at 100% when personally performed; direction modifiers such as QK/QX/QY generally reimbursed at 50%; AD has special base-unit allowances for >4 concurrent procedures), and requires adherence to CMS direction/supervision documentation and modifier submission rules.

Eligibility and service definitions

Eligible provider types

Anesthesia services eligible for payment when furnished by the following providers:

ALL of the following

Physician Anesthesiologist
Certified Registered Nurse Anesthetist (CRNA)
Anesthesiologist Assistant (AA)

Medicare-based anesthesia service types and definitions

Service definitions and when MAC is eligible for coverage (must meet ALL):

ALL of the following

MAC is requested by the attending physician or operating surgeon
Performance of a pre-anesthetic examination and evaluation
There is a prescriptive anesthesia plan outlining the anesthesia care required
Administration of necessary oral and parenteral medication takes place
There is continuous physical presence of the anesthesiologist or, in case of medical direction, a qualified anesthetist

Medically Directed vs Medically Supervised vs Personally Performed

Payment and presence rules for anesthesiologist involvement:

One of

Medically Directed: Physician directs qualified individuals in two, three, or four concurrent cases and performs required activities (pre-anesthetic exam, prescribes plan, participates in most demanding procedures including induction/emergence when applicable, ensures qualified anesthetist performs delegated parts, monitors at frequent intervals, remains physically present and available, provides post-anesthesia care). Medical record must reflect these activities.
Medically Supervised: Physician supervises more than four procedures concurrently or is performing other services for a significant period while directing concurrent procedures. Allow three (3) base units, and one (1) additional base unit when it is demonstrated the physician was present at induction.
Personally Performed: Physician personally performed all pre-, intra-, and postoperative anesthesia care; includes teaching physician scenarios and involvement with residents per Medicare rules.

Codes and modifiers

Anesthesia code set (ASA/CPT anesthesia codes)CPT

No codes listed

Anesthesia modifiers (payment-impacting)Modifier

AD	Medical Supervision by a physician; more than 4 concurrent anesthesia procedures. Allow three base units, and one additional time unit when present at induction.
QK	Medical direction of two, three or four concurrent anesthesia procedures involving qualified individuals. Reimbursed at 50% of Medicare allowed amount.
QX	CRNA service with medical direction by a physician. Reimbursed at 50% of Medicare allowed amount.
QY	Medical direction of one qualified non-physician anesthetist by an anesthesiologist. Reimbursed at 50% of Medicare allowed amount.
G8	MAC for deep, complex, or markedly invasive procedures. Informational; submit with personally performed or appropriate medical direction modifier. Submit actual time.
G9	MAC for patient with history of severe cardiopulmonary condition. See G8 for submission and payment guidance.
QS	Monitored anesthesia care service (can be used by physician or qualified non-physician anesthetist). See G8.
AA	Anesthesia services performed personally by the anesthesiologist. Reimbursed at 100% of Medicare allowed amount.
QZ	CRNA service without medical direction by a physician. Reimbursed at 100% of Medicare allowed amount.
GC	Services performed by a resident under the direction of a teaching physician. Reported to indicate compliance with CMS teaching physician rules; payment may vary by scenario.

Physical status modifiers (informational only)Modifier

P1	Normal healthy patient (informational)
P2	Patient with mild systemic disease (informational)
P3	Patient with severe systemic disease (informational)
P4	Patient with severe systemic disease that is a constant threat to life (informational)
P5	Moribund patient who is not expected to survive without the operation (informational)
P6	Declared brain-dead patient whose organs are being removed for donor purposes (informational)

Billing, documentation, and submission rules

Documentation Required

Medical record must document medical direction activities

When billing medically directed anesthesia, the medical record must reflect that the physician performed required direction activities (pre-anesthetic exam, prescribing plan, participation in demanding procedures, monitoring, presence/availability, post-anesthesia care).

Pre-anesthetic examination and evaluation
Prescribes the anesthesia plan
Personally participates in the most demanding procedures (including induction and emergence, if applicable)
Ensures delegated procedures are performed by a qualified anesthetist
Monitors the course of anesthesia at frequent intervals
Remains physically present and available for immediate diagnosis and treatment of emergencies
Provides indicated post-anesthesia care

Billing Rule

Do not submit base units on claim

Providers must not submit anesthesia base units on the claim; Aspirus will include base units in calculating the allowed amount.

Billing Rule

Submit exact anesthesia minutes

Submit the exact number of minutes from preparation for induction to the time the anesthesiologist or CRNA are no longer in personal attendance or continue to be required; Aspirus will convert the minutes submitted to units of service.

Conversion rule: 15 minutes = 1 unit; units calculated to one decimal (minutes / 15 rounded to one decimal)

Billing Rule

Use highest base-unit procedure for allowed amount

The allowed amount is determined based on the anesthesia procedure that has the highest base unit value. Payment uses that base value plus time units multiplied by the current conversion factor per the policy's payment formula.

Billing Rule

Modifier submission with G8/G9/QS

When submitting G8, G9, or QS modifiers, also submit the personally performed or appropriate medical direction modifier and report actual anesthesia time on the claim.

G8: MAC for deep, complex, or markedly invasive procedures (informational) — submit personally performed or appropriate medical direction modifier with this modifier; submit actual time
G9: MAC for patient with history of severe cardiopulmonary condition — follow G8 guidance
QS: Monitored anesthesia care service — see G8 guidance

Quick Reference - Operational Thresholds and Notes

Anesthesia time unit conversion15 minutes = 1 unit; units reported to one decimal (minutes/15)

How to submit timeSubmit exact number of minutes from preparation for induction to end of personal attendance; Aspirus will translate minutes to units

Do not submit base unitsDo not submit anesthesia base units on the claim; they will be included in calculation of allowed amount

Aspirus conversion behaviorAspirus translates submitted minutes into units of service (example: 62 minutes = 4.1 units)

Key terms

Definitions

Base Units or Base ValueThe number of units assigned to the ASA code (00100 - 01999).

Anesthesiologist Assistant (AA)A masters-level educated individual who works collaboratively under direction of an anesthesiologist and performs pre-anesthetic history, exams, monitoring, medication administration, and delegated anesthetic techniques.

Certified Registered Nurse Anesthetist (CRNA)An advanced practice registered nurse with graduate-level education and board certification in anesthesia.

Medically DirectedPhysician medically directs qualified individuals in two, three, or four concurrent cases and performs required supervisory activities; the medical record must reflect these activities.

Medically SupervisedPhysician supervises more than four concurrent procedures or is performing other services while directing concurrent procedures; special base unit allowances apply (see policy).

Monitored Anesthesia Care (MAC)Intra-operative monitoring by an anesthesiologist or qualified provider with pre-anesthetic evaluation, prescriptive plan, medication administration, and continuous presence of anesthesiologist or qualified anesthetist; eligible when criteria are met.

Common Q&A

When selecting modifiers, bill the modifier that reflects how the service was provided: use AA or QZ for personally performed services, QK/QX/QY for medically directed services, and AD when medically supervising more than four concurrent cases (AD allows 3 base units and +1 base unit if physician was present at induction). For MAC modifiers (G8/G9/QS), submit the personally performed or appropriate medical direction modifier with the MAC modifier and report actual time on the claim. Direction/supervision modifiers materially affect payment (e.g., medically directed typically reimbursed at 50% of the allowed amount; personally performed at 100%).

Report exact anesthesia minutes from preparation for induction to the time the anesthesiologist or CRNA are no longer in personal attendance; do not submit base units on the claim (Aspirus will include base units in calculating the allowed amount). Aspirus converts minutes to units at 15 minutes = 1 unit and calculates units to one decimal (minutes/15 rounded to one decimal). Billing staff must ensure the correct time is entered and that the appropriate ASA code (highest base unit procedure) and modifier combination are submitted to produce the correct allowed amount per the reimbursement formula.

Policy changes

2021-01-01initial_publication

January 1, 2021 - Anesthesia policy published by Aspirus Health Plan.

2023-06-22annual_review

June 22, 2023 - Annual policy review completed; updates made to definitions, provider eligibility, and Modifiers/CPT/HCPCS/Revenue Codes sections.

2024-04-19annual_review

April 19, 2024 - Annual review completed; intent unchanged; wording and grammar updated.

2025-03-17annual_reviewLatest

March 17, 2025 - Annual review complete. Updates to definition and payment information sections for clarity.