CurrentBlue Cross Blue Shield - IllinoisPolicy CPCP010

Anesthesia Information

Governs coding, billing, and payment methodology for anesthesia services billed to Blue Cross Blue Shield of Illinois; applies to in-network professional providers and others submitting claims per provider contracts and plan documents.

Policy Summary

PayerBlue Cross Blue Shield - Illinois

PolicyAnesthesia Information

Policy CodePolicy CPCP010

Change TypeAnnual review (02/09/2024)

Effective DateAug 14, 2024

Next Review Date

Key ActionProviders must submit accurate documentation and may be asked to provide additional documentation upon request; claims are subject to claim review and code edit protocols.

SourceLink

POLICY UPDATE CHANGES

Annual Review approved by the Enterprise Clinical Payment and Coding Policy Committee on February 9, 2024.

CPCP010policy identifier

12-minutetime increment

Time+Base+Modunit formula

99100,99116,99135,99140example add-ons

Anesthesia Coverage and Payment Criteria

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Anesthesia coverage and payment criteria

Payment determinations and limitations for anesthesia services.

Anesthesia procedure codes may be eligible for payment based on time and points methodology; claims are subject to code edit software and provider contract; when multiple surgical procedures occur during one anesthesia administration, bill the anesthesia procedure code for the most complex service and report combined time.

Total units allowed = (Time Units + Base Units Value + Modifying Unit(s) Value); allowable amount = total units x anesthesia conversion factor.

Time units are calculated in 12-minute increments and reported as the combined total for all procedures performed during the same anesthesia administration.

Base units are derived from the ASA Relative Value Guide; base points in effect on the date of service are used to process claims.

Included services: preoperative and postoperative visits; administration of fluids and/or blood products incident to anesthesia care (including venipuncture/introduction of needle or catheter); laryngoscopy and/or bronchoscopy; retrobulbar injection; cardiopulmonary resuscitation, cardioversion, temporary pacemaker, or inhalation treatments. These are included in the base unit value and are not separately reimbursable.

Appropriate anesthesia modifiers must be appended to identify personal performance, medical supervision, or medical direction; physical status and second-position modifiers may be used per the policy.

Qualifying circumstance add-on codes (for example 99100, 99116, 99135, 99140) may add units when applicable and should be reported only with the anesthesia service having the highest Base Unit Value.

Multiple procedures: Report a single anesthesia code for the highest Base Unit Value plus combined time for all procedures on the same date of service; if multiple general anesthesia codes (00100-01999) are submitted, only the highest submitted will be eligible for reimbursement and secondary general anesthesia services will be denied, except for specified add-on anesthesia codes (e.g., 01953, 01968, 01969).

Duplicate services: When duplicate anesthesia services are billed for the same patient on the same date by the same or different clinicians, the claim will be denied or only the first submission of that code will be reimbursed; simultaneous physician and CRNA services may be reported with appropriate modifiers.

Limitations and exclusions: Certain procedure codes may be excluded from the time-and-points methodology per fee schedules; reimbursement for CPT 00104 is not allowed when anesthesia is performed by a psychiatrist in addition to ECT (CPT 90870).

Modifier 22 (substantial additional work/field avoidance) may be used when documentation in the anesthesia record supports substantially greater work (requirements include inclusion in anesthesia record, base unit less than 5, procedure around head/neck/shoulder girdle and/or non‑supine position); additional payment for field avoidance is subject to documentation review.

Procedure, Qualifying Circumstances, and Time Units

Anesthesia procedure codesCPTCovered

00100-01999

General anesthesia procedure code range; only highest-valued general anesthesia service reimbursed when multiple submitted

Qualifying circumstance add-on codesCPTCovered

99100	Qualifying circumstance add-on
99116	Qualifying circumstance add-on (ANESTHESIA, LOW BODY TEMP)
99135	Qualifying circumstance add-on (ANESTHESIA, LOW BLOOD PRESSURE)
99140	Qualifying circumstance add-on (ANESTHESIA IN EMERGENCY)

Time unit increment

Time unit increment12-minute increments used to calculate anesthesia time units

Calculation ruleTime is converted to units in 12-minute increments for time-based anesthesia codes

Usage contextApplied when computing Time Units in the Total Units Allowed formula

Documentation and Claim Review Responsibilities

Documentation Required

Documentation, claim review, and requests for additional records

Providers are responsible for submitting accurate documentation and claims using valid HIPAA-approved code sets; claims are subject to code edit protocols and claim review, and BCBSIL may request additional documentation to support billed services.

Submit claims coded appropriately according to industry standard coding guidelines (e.g., UB, AMA CPT, HCPCS, ICD-10-CM/PCS, NDC, DRG, CMS NCCI).
Be prepared to provide additional documentation upon request to support services billed; provider is urged to submit requested records.

Key Definitions and Payment Calculation

Anesthesia services

DefinitionAnesthesia services include usual pre-operative and post-operative visits, anesthesia care during the procedure, administration of fluids and/or blood, usual physiologic monitoring (e.g., ECG, temperature, blood pressure, oximetry, capnography, mass spectrometry), and other supportive services

Included proceduresIntra-arterial, central venous, and Swan-Ganz catheter insertion allowed separately; laryngoscopy/bronchoscopy and certain resuscitation procedures are included in base units and not separately reimbursable

Coding guidanceServices should be reported using CPT anesthesia five-digit procedure codes or CPT surgical codes plus appropriate modifier; report a single code when it describes the services

Modifiers and Physical Status Modifiers

Primary anesthesia modifiersAA (anesthesia services performed personally by anesthesiologist), AD (medical supervision by physician of >4 concurrent cases), QK (medical direction of 2–4 concurrent anesthesia procedures), QY (medical direction of one CRNA), QX (CRNA service with medical direction), QZ (CRNA service without medical direction)

Second-position modifiersQS (MAC), G8 (MAC for deep/complex procedures), G9 (MAC for severe cardiopulmonary condition), GC, GE, GF, 22, 23, 47

Physical status modifiersP1–P6 (ASA I–VI classifications); note: physical status modifiers are not used to determine payment

Payment calculation

Total units formulaTotal units allowed = (Time Units + Base Units Value + Modifying Unit(s) Value) x Conversion Factor

Base units sourceBase unit (base points) derived from ASA Relative Value Guide and base unit value is used as of the date of service

Allowable amountAllowable amount equals the anesthesia conversion factor multiplied by the total units