CurrentAvMedPolicy N/A

Anesthesia Payment Policies

Defines AvMed reimbursement rules for anesthesia services (CPT 00100-01999) including time-based methodology, base values, modifiers, qualifying circumstances, and specific rules for obstetric neuraxial labor analgesia. Applies to all products, network and non-network physicians, and other qualified health care professionals.

Policy Summary

PayerAvMed

PolicyAnesthesia Payment Policies

Policy CodePolicy N/A

Change TypeAdded cap for CPT 01967; revision history updated

Effective Date7/15/20

Next Review Date

Key ActionEnsure facility medical record documents anesthesia start/stop times; if conflict with practitioner claim, facility record will determine reimbursement

SourceLink

POLICY UPDATE CHANGES

Effective 7/15/20, cap of 435 minutes applied to reimbursement of neuraxial labor analgesia (CPT 01967).

Origination and revision history entries include dates 9/15/2014 and 4/5/2020.

00100-01999Anesthesia CPT range covered

6Concurrency modifier options listed

4Qualifying circumstance codes described

435Neuraxial labor analgesia cap (minutes)

Policy Summary

AvMed's anesthesia reimbursement policy aligns with CMS NCCI Policy Manual, NCCI edits, and the CMS National Physician Fee Schedule and applies to all products, network and non-network physicians, and other qualified health care professionals. It covers anesthesia CPT codes 00100-01999 and establishes CMS-assigned Base Units, a time-based methodology with Anesthesia Time reported in 1-minute increments (converted to 10- or 15-minute Time Based Units depending on provider contract and rounded to the first decimal), concurrency modifier percentages, qualifying circumstance codes and units, the standard anesthesia Reimbursement Formula, and a special obstetric rule for neuraxial labor analgesia.

The policy defines: (1) Base Value — CMS-assigned base units for each anesthesia CPT code that include usual pre/post-operative visits, fluids/blood administration incident to anesthesia, and interpretation of non-invasive monitoring; when multiple procedures occur during one anesthesia administration only the anesthesia code with the highest Base Value is reported; (2) Time Based Units and Anesthesia Time start/stop definitions and facility record precedence if times conflict; (3) required concurrency modifiers in the first modifier position with CMS-consistent Allowed Percentages (AA 100%, AD 100%, QK/QX/QY 50%, QZ 100%); (4) Qualifying Circumstances codes (99100, 99116, 99135, 99140) with specified modifying units and exclusions; and (5) the Reimbursement Formula: (Base Unit Value + Time Units) X Conversion Factor X Concurrency Modifier Percentage = Allowed Amount.

Special obstetric rule (effective 7/15/20): AvMed will reimburse neuraxial labor analgesia (CPT 01967) using the Reimbursement Formula subject to a cap of 435 minutes, and add-on CPT codes 01968 and 01969 are eligible for reimbursement when billed with primary CPT 01967.

Policy dates: Origination/revision history entries include dates 9/15/2014 and 4/5/2020; last review 2020-04-05. (No other effective/next_review dates provided in the source.)

Key thresholds & quick facts

Anesthesia Time reporting incrementReport actual Anesthesia Time in 1 minute increments

Time Based Units conversionConverted to 10‑minute or 15‑minute units depending on provider contract; rounded to the first decimal

Neuraxial labor analgesia capCap for CPT 01967 = <= 435 minutes (effective 2020-07-15)

Anesthesia CPT range coveredCPT codes 00100-01999

Concurrency modifier options count6 modifiers (AA, AD, QK, QX, QY, QZ)

Qualifying circumstance codes count4 codes (99100, 99116, 99135, 99140)

General Reimbursement Criteria

General Reimbursement Rules

ALL of the following

Anesthesia services must be submitted with a CPT anesthesia code in the range 00100-01999 and are reimbursed utilizing a time-based methodology according to the standard anesthesia formula.
Each CPT anesthesia code (00100-01999) is assigned a Base Value by CMS; the Base Value includes usual pre-operative and post-operative visits, administration of fluids/blood products incident to anesthesia care, and interpretation of non-invasive monitoring. When multiple surgical procedures are performed during a single anesthesia administration, only the single anesthesia code with the highest Base Value is reported.
Anesthesia Time must be reported in one-minute increments. Anesthesia Time begins when the anesthesia practitioner begins to prepare the patient for anesthesia services in the operating room and ends when the anesthesia practitioner is no longer furnishing anesthesia services to the patient.
If there is a conflict between Anesthesia Time reported by the anesthesia practitioner on the professional claim and the Anesthesia Time documented in the facility medical record, the facility record will be the basis for reimbursement.
Placement of post-surgical pain blocks performed before anesthesia induction or after anesthesia emergence are not to be added to the reported anesthesia time.
Depending on the provider contract, AvMed will convert the reported Anesthesia Time into either 10-minute or 15-minute Time Based Units. The Time Based Units will be rounded to the first decimal.
All anesthesia services must be submitted with a required concurrency modifier in the first modifier position that identifies whether a procedure was personally performed, medically directed, or medically supervised. AvMed will adjust the allowed amount by the modifier percentage listed in the Modifiers and Allowance Percentages criteria group.

Qualifying Circumstances

ALL of the following

Qualifying circumstances codes identify conditions that significantly affect the nature of the anesthesia services provided and should only be billed in addition to the anesthesia service with the highest Base Value.
If the member meets the clinical criteria for the qualifying circumstances codes and they are billed with the appropriate anesthesia code, the Modifying Units will be added to the Base Value.
Qualifying Circumstance Codes
- 99100 — Anesthesia for patient of extreme age: younger than 1 year and older than 70. Not allowed with anesthesia codes 00326, 00561, 00834, and 00836.Modifying Units = 1
- 99116 — Anesthesia complicated by utilization of total body hypothermia. Not allowed with anesthesia codes 00561, 00562, 00563, and 00567.

Obstetric Anesthesia Services

ALL of the following

Effective 7/15/2020, neuraxial labor analgesia (CPT 01967) will be reimbursed using the standard Reimbursement Formula [(Base Unit Value + Time Units) x Conversion Factor x Concurrency Modifier Percentage] subject to a cap of 435 minutes for reported Anesthesia Time.
Add-on CPT codes 01968 and 01969 (C-Section Anesthesia) are eligible for reimbursement when billed with the primary CPT code 01967 (Vaginal Delivery Anesthesia).

Modifiers and Allowance Percentages

ALL of the following

Concurrency modifiers adjust the allowed amount by the percentages listed below. These modifiers must be reported in the first modifier position on anesthesia claims.
AA — Anesthesia services performed personally by an anesthesiologist. Allowed Percentage = 100%.
AD — Medical supervision by a physician with more than four concurrent anesthesia procedures. Allowed Percentage = 100%.
QK — Medical direction of two, three, or four concurrent anesthesia procedures involving qualified individuals. Allowed Percentage = 50%.
QX — Qualified non-physician anesthetist with medical direction by a physician. Allowed Percentage = 50%.

Billing & Documentation Rules

Documentation Required

Anesthesia Time source priority

When facility medical record anesthesia start/stop times conflict with the practitioner claim, the facility record will be used as the basis for reimbursement.

00100-01999

Billing Rule

Submit concurrency modifier in first modifier position

All anesthesia services must include the required concurrency modifier in the first modifier position. AvMed will adjust the allowed amount by the concurrency modifier percentage consistent with CMS.

Billing Rule

Time reporting and unit conversion

Report actual Anesthesia Time in one-minute increments. AvMed will convert reported minutes to either 10-minute or 15-minute time-based units depending on provider contract and round the resulting time units to the first decimal.

00100-01999

Billing Rule

Do not include certain blocks in anesthesia time

Do not add post-surgical pain blocks placed before anesthesia induction or after anesthesia emergence to the reported anesthesia time.

00100-01999

Billing Rule

Neuraxial labor analgesia cap enforcement

Effective 7/15/20, reimbursement for neuraxial labor analgesia (CPT 01967) is subject to a cap of 435 minutes.

01967
Note: Add-on codes 01968 and 01969 are eligible for reimbursement when billed with 01967

Billing Rule

Qualifying circumstance usage

Bill qualifying circumstance codes only in addition to the anesthesia code with the highest Base Value and observe the listed 'not allowed with' exclusions for specific anesthesia codes.

99100 (not allowed with 00326, 00561, 00834, 00836)
99116 (not allowed with 00561, 00562, 00563, 00567)
99135 (not allowed with 00561, 00562, 00563, 00567)
99140

OpenPayer

Anesthesia Payment Policies

Policy Summary

General Reimbursement Criteria

Code Lists

Billing & Documentation Rules

Reimbursement Formula

Key Terms

Policy Changes & Timeline

01967	Neuraxial labor analgesia — reimbursed per Reimbursement Formula subject to cap of 435 minutes (effective 2020-07-15)
01968	Add-on C-section anesthesia — eligible for reimbursement when billed with primary CPT 01967
01969	Add-on C-section anesthesia — eligible for reimbursement when billed with primary CPT 01967