CurrentBaylor Scott & White Health PlanPolicy 289

Anesthesia Professional Reimbursement

Defines reimbursement methodology, billing requirements, eligible and ineligible separately billable anesthesia-related services, modifiers, qualifying circumstance codes, physical status modifiers, time unit calculation and CRNA/medical direction payment rules for Baylor Scott & White Health Plan.

Policy Summary

PayerBaylor Scott & White Health Plan

PolicyAnesthesia Professional Reimbursement

Policy CodePolicy 289

Change TypeReviewed / Updated / New

Effective DateFeb 1, 2026

Next Review DateJan 22, 2027

Key ActionProviders must submit total minutes and time units on the claim and include appropriate anesthesia modifiers and qualifying circumstance codes as applicable.

SourceLink

POLICY UPDATE CHANGES

01/22/2026 Reviewed, Action = No changes

08/11/2025 Updated, Action = Removed, 'Medicare NCD or LCD specific InterQual criteria may be used when available.'

02/12/2024 Reviewed, Action = Formatting changes and added hyperlink to TMPPM resources, beginning and ending note sections updated to align with CMS requirements and business entity changes.

03/25/2021 New policy created (transitioned from FirstCare policy)

MultipleAnesthesia CPT codes referenced

QK,QY,QX,QZ,AD,23Key modifiers required/used

99100/99116/99135/99140Qualifying circumstance codes

P1-P6

Physical status modifiers

Coverage Summary

This policy (Policy Number 289) defines Baylor Scott & White Health Plan's anesthesia professional reimbursement methodology. Compensation is calculated using CMS-assigned Base Units plus Time Units multiplied by an anesthesia Conversion Factor, and requires the appropriate anesthesia modifier and the duration of the procedure in minutes to be submitted on the claim.

The policy applies to all lines of business unless superseded by applicable federal or state mandates: for Medicare plans follow relevant NCD/LCD criteria, and for Medicaid plans confirm coverage per the Texas Medicaid Provider Procedures Manual (TMPPM). In the absence of controlling federal or state coverage mandates, benefits are determined by the member's plan document.

Effective date: 02/01/2026. Last review: 01/22/2026. Next review: 01/22/2027.

Key thresholds & quick facts

Time unit calculation1 time unit = 15 minutes; compute time units by dividing reported minutes by 15 and round to one decimal place (nearest tenth). If system cannot use decimals, BSWHP rounds up to a full time unit when actual anesthesia time is or exceeds 8 minutes of a 15-minute unit.

Obstetrical delivery time defaultIf no definitive delivery time is available, use 1 hour as delivery time (and report 1 time unit per hour of labor for continuous infusion epidural).

Key modifiers usedCommon modifiers required/used include QK, QY, QX, QZ, AD for medical direction/supervision and 23 for unusual anesthesia; modifier 59 identifies distinct nerve block/epidural for separate reimbursement.

Provider types and payment rules (Anesthesiologist/CRNA)CRNA recognized as eligible practitioner; medically directed CRNA services paid at 50% of calculated reimbursement with physician able to bill up to remaining 50%; when CRNA not medically directed, full allowed rate payable to CRNA; combined payments will not exceed 100% of total eligible reimbursement. Appropriate HCPCS Q-modifiers (QK, QY, QX, QZ, AD) must be used.

Medical-Necessity & Reimbursement Criteria

General reimbursement methodology

Covered when ALL of the following are met:

Compensation based on (Base Units + Time Units) x Anesthesia Conversion Factor

Base units from CMS; Time and total minutes submitted on claim by provider; Conversion factor = BSWHP contracted rate

Appropriate anesthesia modifier must be filed and duration of procedure in minutes reported

Providers must submit total minutes and time units on the claim; include appropriate anesthesia modifiers and qualifying circumstance codes as applicable

Anesthesia time definition: Anesthesia time defined as continuous presence of anesthesiologist/anesthetist from initial preparation for anesthesia care to placement under postoperative supervision

Definition source: policy definitions

Coding

Anesthesia base/time/related procedure codes coveredCPTCovered

01960	Anesthesia for vaginal delivery (used when converted to general anesthesia)
01961	Anesthesia for cesarean delivery (used when converted to general anesthesia)
01967	Anesthesia for labor epidural (vaginal delivery)
01968	Anesthesia for labor epidural (cesarean delivery)
01996	Daily management of therapeutic epidural administration
31500	Emergency intubation
64400	Injection, anesthetic agent; trigeminal nerve, any division or branch
64402	Injection, anesthetic agent; facial nerve
64405	Injection, anesthetic agent; greater occipital nerve
64408	Injection, anesthetic agent; vagus nerve

1–10 of 28

1/3

Qualifying circumstance and physical status codes (additional units)CPT|ModifierCovered

99100	Extreme age - 1 unit
99116	Total body hypothermia - 5 units
99135	Controlled hypotension - 5 units
99140	Emergency conditions - 2 units
P1	Physical status modifier P1 - 0 units
P2	P2 - 0 units
P3	P3 - 1 unit
P4	P4 - 2 units
P5	P5 - 3 units
P6	P6 - 0 units

1–10 of 11

1/2

Non-separately reimbursable by anesthesiologistsCPTNot Covered

99151	Moderate sedation initial 15 minutes - not reimbursable by anesthesiologists
99152	Moderate sedation each additional 15 minutes - not reimbursable by anesthesiologists

Anesthesiologist performed procedures reimbursed under physician fee scheduleCPTCovered

93503	Swan-Ganz catheter insertion
36555	Insertion non-tunneled centrally inserted central venous catheter; younger than 5 years
36556	Insertion non-tunneled centrally inserted central venous catheter; age 5 years or older
36568	Insertion of PICC without subcutaneous port or pump; younger than 5 years
36569	Insertion of PICC without subcutaneous port or pump; age 5 years or older
36580	Replacement complete of non-tunneled central venous catheter through same venous access
36584	Replacement complete of PICC through same venous access
36620	Arterial catheterization/cannulation percutaneous
36625	Arterial catheterization/cannulation cutdown
93312	TEE with probe placement, acquisition, interpretation and report

1–10 of 16

1/2

Medical direction/supervision modifiers (HCPCS) reimbursedModifierCovered

AD	Medical supervision by a physician; more than four concurrent anesthesia procedures
QK	Medical direction of two, three, or four concurrent anesthesia procedures involving qualified individuals
QY	Medical direction of one CRNA by an anesthesiologist
QX	CRNA service with medical direction by a physician
QZ	CRNA service without medical direction by a physician

Provider Actions & Billing Rules

Documentation Required

Report anesthesia time and modifiers

Providers must submit the total anesthesia minutes and calculated time units on the claim, and include appropriate anesthesia modifiers and qualifying circumstance codes as applicable. Base units are obtained from CMS and used in the (Base Units + Time Units) x Conversion Factor reimbursement methodology.

Billing Rule

Time unit reporting and rounding

Report actual anesthesia time in minutes. Time units = minutes / 15, rounded to one decimal place (nearest tenth). If system constraints prohibit decimal rounding, BSWHP rounds up to a full time unit when the actual anesthesia time is or exceeds eight (8) minutes of a single 15‑minute unit.

Definitions

Anesthesia time: Continuous presence of the anesthesiologist or anesthetist from first preparation for anesthesia care to placement under postoperative supervision.

Time unit: One unit per 15 minutes of anesthesia. Compute by dividing reported minutes by 15 and rounding to one decimal place (nearest tenth). If system constraints prevent decimal rounding, BSWHP rounds up to a full time unit when actual anesthesia time is or exceeds 8 minutes of a 15-minute unit.

Deep Sedation: A drug-induced depressed level of consciousness in which patients cannot be easily aroused but respond purposefully after repeated or painful stimuli; airway intervention may be required.

Epidural Anesthesia: Administration of a narcotic drug either through an epidural catheter or by a single-dose injection.

PCA (Patient Controlled Analgesia): Pain management involving the self-administration of intravenous drugs through an infusion device; BSWHP reimburses initial catheter insertion when not part of surgical anesthesia and will reimburse postoperative PCA evaluation/management when billed with an appropriate E/M and supporting documentation.

Revision History

01/22/2026ReviewedLatest

01/22/2026 Reviewed, Action = No changes

08/11/2025Updated

08/11/2025 Updated, Action = Removed, 'Medicare NCD or LCD specific InterQual criteria may be used when available.'

02/12/2024Reviewed

02/12/2024 Reviewed, Action = Formatting changes and added hyperlink to TMPPM resources, beginning and ending note sections updated to align with CMS requirements and business entity changes.

Policy Summary

PayerBaylor Scott & White Health Plan

PolicyAnesthesia Professional Reimbursement

Policy CodePolicy 289

Change TypeReviewed / Updated / New

Effective DateFeb 1, 2026

Next Review DateJan 22, 2027

Key ActionProviders must submit total minutes and time units on the claim and include appropriate anesthesia modifiers and qualifying circumstance codes as applicable.

SourceLink

On This Page

Time unit calculation and rounding:

Time units = 1 unit per 15 minutes; report actual anesthesia time in minutes; compute time units = reported minutes / 15 and round to one decimal place (nearest tenth). If system cannot round to decimal, BSWHP rounds up to a full time unit when actual anesthesia time is or exceeds eight (8) minutes of a single 15-minute unit

1 unit = 15 minutes; rounding to nearest tenth; >=8 minutes rounds up if decimals not supported

See provider actions and thresholds

Physical status modifiers

Modifiers billed by anesthesiologists/CRNAs add units as specified:

P1 - A normal healthy person0 units