CurrentBlue Cross Blue Shield - MainePolicy N/A

Professional Anesthesia Services (MA PPO)

Defines Anthem Medicare Advantage reimbursement rules for professional anesthesia services including time reporting, modifiers, qualifying circumstances, included/excluded services, postoperative pain management, and coding/billing conventions. Applies to participating providers and facilities for anesthesia professional claims.

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyProfessional Anesthesia Services (MA PPO)

Policy CodePolicy N/A

Change TypeBiennial review / clarifications

Effective DateNov 25, 2020

Next Review DateN/A

Key ActionProviders must document start and stop times in the medical record and report anesthesia minutes in one-minute increments; failure may result in claim rejection/denial.

SourceLink

POLICY UPDATE CHANGES

Biennial Review: definition section updated and language changes

Added and updated multiple historical coding and modifier clarifications over time (2010-2020)

Time-basedReimbursement method

MultipleCode groups referenced

ConditionalSeparate reimbursement

Policy scope and summary

Policy subject: Professional Anesthesia Services reimbursement. This policy defines reimbursement for participating providers for anesthesia services and follows the American Society of Anesthesiologists (ASA) anesthesia formula.

Reimbursement method: Time-based — payment is calculated using the ASA formula that combines Base Units plus Time Units (minutes reported ÷ 15, rounded to the nearest tenth) and any applicable Physical Status modifiers. Facility drug charges (including Propofol) are generally considered bundled into the facility charge and are not eligible for separate professional reimbursement.

Scope: Applies to participating providers and facilities for professional anesthesia claims and incorporates NCCI/CMS guidance, requirements for proper modifiers, qualifying circumstances, included/excluded services, postoperative pain management, and coding/billing conventions.

Policy metadata

PayerBlue Cross Blue Shield - Maine

Policy titleProfessional Anesthesia Services (MA PPO)

Policy numberN/A

Effective date11/25/2020

Last review09/22/2021

StatusCURRENT

Scope summaryDefines Medicare Advantage reimbursement rules for professional anesthesia services including time reporting, modifiers, qualifying circumstances, included/excluded services, postoperative pain management, and coding/billing conventions; applies to participating providers and facilities for anesthesia professional claims.

Reimbursement methodTime-based (ASA formula: base units + time units + physical status modifiers)

Coverage & reporting criteria

Time reporting and reimbursement calculation

Anesthesia time and units requirements:

Report minutes: Report anesthesia services in one-minute increments and note minutes in the units field
Time calculation: Reimbursement calculation: number of minutes reported divided by 15 and rounded to the nearest tenth to provide time unitsminutes reported / 15, rounded to nearest tenth
Start/stop documentation: Start and stop times must be documented in the medical record
Definition of anesthesia time: Anesthesia time starts with preparation for administration and stops when provider is no longer in personal attendance
Interruptions: Anesthesia time can be counted in blocks if interruptions occur, counting only continuous anesthesia service time
Rejection risk: Claims submitted with an indicator other than minutes may be rejected or denied

Use of anesthesia modifiers

Modifiers and who performed service; billing field requirements:

Append modifiers: Append appropriate anesthesia modifiers to procedure code to indicate specific anesthesia service or who performed it
Primary modifier field: Modifiers identifying who performed anesthesia must be billed in the primary modifier field to receive appropriate reimbursement
G8/G9/QS allowance for MAC: Modifiers G8, G9, or QS may be reported in a subsequent modifier field when the service rendered is monitored anesthesia care (MAC)
Denial if missing: Claims submitted without appropriate modifier will be denied

Physical status modifiers

Physical status modifier reimbursement:

Purpose: Physical status modifiers (P1-P6 etc.) identify condition complexity and unit values assigned per ASA guidance
Unit values applied: Anthem follows ASA recommendation that unit values are assigned to physical status modifiers for additional reimbursement when appended to base anesthesia code

Multiple procedures

Reporting when multiple surgical procedures occur:

Most complex only: Report only anesthesia code for the most complex service; base units used only for primary procedure
Denial of lesser-charge: If two separate anesthesia codes are reported, the lesser-charge procedure will be denied
Add-on exceptions: Exception: Add-on codes 01953, 01968, 01969 are eligible for separate reimbursement in addition to primary procedure
Separate subsequent session: If Anthem determines a separate subsequent operative session occurred with >1 hour separation from initial anesthesia, second anesthesia may be eligible for separate reimbursement

Field avoidance and unusual positioning

Minimum base value requirement:

Minimum base value: Procedures requiring field avoidance or positions other than supine or lithotomy have a minimum base value of 5 regardless of lesser assigned base value>= 5 base units
No additional reimbursement for field avoidance: Field avoidance is not eligible for additional reimbursement even when reported with modifier 22

Qualifying circumstances (additional reporting)

Codes reportable in addition to base anesthesia service:

Qualifying circumstance codes group

Qualifying circumstance codes: 99100: Anesthesia for patient of extreme age (younger than 1 year and older than 70); 99116: Anesthesia complicated by utilization of the total body hypothermia; 99140: Anesthesia complicated by emergency conditions; 99135: Anesthesia complicated by utilization of controlled hypotension
Mutual exclusivity: Anthem will determine mutually exclusive relationships between qualifying circumstance codes and reported base anesthesia code
99140 obstetric exception: CPT 99140 eligible for separate reimbursement for emergency services, except when reported for an unscheduled routine obstetric delivery with listed diagnosis codes (those diagnosis codes are specified in related coding table)
See related coding table for diagnosis codes

Oral surgery anesthesia

CDT vs CPT reporting rules for oral surgery:

Oral surgery anesthesia - CDT vs CPT

Allow CDT: Allow reimbursement for anesthesia for covered oral surgical procedures reported with CDT anesthesia codes D9210-D9248
Disallow CPT when CDT reported: Do not allow reimbursement when same claim reports both CDT anesthesia codes D9210-D9248 and CPT anesthesia codes 00170-00176 (CPT intraoral anesthesia codes will not be eligible when reported with CDT procedures)
Modifier 47 for oral surgeon CPT: Oral surgeon reporting services with a CPT procedure and providing anesthesia must append modifier 47; in this instance there is no additional reimbursement for anesthesia

Services included in global anesthesia reimbursement (not eligible separately)

Anthem considers the following included in global anesthesia reimbursement:

Included services list

PCA management: Daily hospital management of patient-controlled analgesia (when patient controls analgesia amount)
Echocardiography incidental: Echocardiography (unless distinct and independent TEE with appropriate modifier)
Inhalation treatments
EEG: Electroencephalogram (EEG)

Services eligible for separate reimbursement with anesthesia

Services eligible separately when performed with anesthesia:

Separately reimbursable services

Invasive lines and TEE distinct: Central venous pressure (CVP) line insertion; Swan-Ganz catheter insertion; Intra-arterial line insertion; Transesophageal echocardiography (TEE) when performed as distinct and independent procedure (codes 93312-93317) with appropriate modifier appended
TEE incidental codes: TEE services for monitoring purposes (CPT 93318) or for guidance of transcatheter intracardiac or great vessel structural interventions (CPT 93355) will follow NCCI edit logic and are considered incidental; a bypass modifier will not override

Medication reporting in facility setting

Separate reporting of medications by professional provider:

Facility medication bundled: When a professional provider separately reports a medication in a facility setting, the medication will not be eligible for separate reimbursement (including Propofol)
Facility charge includes meds: Anthem considers provision of medication to be included under the facility's charge

Postoperative pain management reimbursement

Postoperative pain management reimbursement:

Postoperative pain management codes and rules

Eligible injection/catheter codes: Postoperative management services by anesthesiologist (injection or catheter into epidural space or major nerve) are eligible for separate reimbursement; time units not applicable; applicable codes: 62320-62327, 64413-64425, 64445-64450
Bilateral reporting and allowance: When performed bilaterally, report unilateral code once with modifier 50; service considered one surgical service and eligible for reimbursement equal to 150% of allowance for the code150% allowance when modifier 50 used
Injection in addition to anesthesia: Epidural or major nerve injection/catheter performed for postoperative management before, during, or following surgery is eligible in addition to primary anesthesia code; append appropriate modifier to indicate distinct procedural service

Code lists and coding guidance

Qualifying circumstance codes eligible in addition to base anesthesiaCPTCovered

99100	Anesthesia for patient of extreme age (younger than 1 year and older than 70)
99116	Anesthesia complicated by utilization of the total body hypothermia
99140	Anesthesia complicated by emergency conditions
99135	Anesthesia complicated by utilization of controlled hypotension

Add-on anesthesia codes eligible separate reimbursementCPTCovered

01953	Add-on code (eligible separately per policy)
01968	Add-on code (eligible separately per policy)
01969	Add-on code (eligible separately per policy)

Postoperative pain management codes eligible separatelyCPTCovered

62320-62327	Epidural/spinal injection and catheter codes for postoperative management
64413-64425	Peripheral nerve injection codes for postoperative management
64445-64450	Other nerve block codes for postoperative management
01996	Daily hospital management of epidural/subarachnoid continuous drug administration (eligible once per date of service; not eligible when billed with an injection code)

TEE codes eligible separately when distinct/independentCPTCovered

93312-93317

Transesophageal echocardiography codes eligible separately if performed as distinct and independent procedure with appropriate modifier

TEE/echocardiography codes considered incidental with anesthesia (not separately reimbursed)CPTNot Covered

93318	TEE for monitoring purposes - considered incidental and not eligible separately
93355	TEE guidance of transcatheter intracardiac/great vessel interventions - considered incidental and not eligible separately

Oral surgery CDT codesmixedCovered

D9210-D9248

CDT anesthesia codes for oral surgical procedures (eligible when reported with CDT procedures)

CPT intraoral anesthesia codes (not eligible when reported with CDT procedures)CPTNot Covered

00170-00176

Anesthesia for intraoral procedures - not eligible when reported with CDT procedures (CDT codes D9210-D9248)

Certain diagnosis-specific exceptions (for example, the limitation that CPT 99140 is not separately reimbursed when reported for an unscheduled routine obstetric delivery) reference diagnosis lists maintained in the related coding tables.

Consult the policy's related coding table for the specific diagnosis codes that determine these exceptions before billing.

Billing, documentation & denial risk

Documentation Required

Document anesthesia start/stop times and minutes

Providers must document start and stop times in the member's medical record and report anesthesia minutes in one-minute increments; failure to report minutes may result in claim rejection or denial.

Billing Rule

Bill modifiers in primary modifier field

Modifiers identifying who performed the anesthesia (for example AA, AD, QK, QX, QY, QZ) must be billed in the primary modifier field to receive appropriate reimbursement. Note: modifiers G8, G9, or QS may be reported in a subsequent modifier field when the service rendered is monitored anesthesia care (MAC).

Billing Rule

Do not separately bill medications in facility setting

When a professional provider separately reports a medication in a facility setting, the medication will not be eligible for separate reimbursement. Anthem considers provision of medication, including Propofol, to be included under the facility's charge.

Billing Rule

Multiple anesthesia procedures billing

When anesthesia services are provided for multiple surgical procedures, report only the anesthesia procedure code for the most complex service. If two separate anesthesia codes are reported, the lesser-charge procedure will be denied. Exception: the add-on codes listed below are eligible for separate reimbursement in addition to the primary procedure.

01953
01968
01969

Denial Risk

Claims without appropriate modifiers may be denied

Claims submitted for anesthesiology services without the appropriate modifier will be denied.

Billing Rule

01996 daily management billing constraint

CPT 01996 (daily hospital management of continuous epidural/subarachnoid drug administration) is eligible once per date of service following the surgery date. However, when 01996 is billed with an anesthetic injection code (for example, CPT codes 62320-62327), only the injection code is eligible for reimbursement. Modifiers will not override these edits.

01996
62320-62327

Billing Rule

QK/QX/QY reduction for spinal/nerve injection codes

When modifier QK, QX, or QY is appended to applicable spinal/nerve injection codes, a reimbursement percentage of 50% will apply.

Key definitions

Definitions

AnesthesiaAdministration of medication to allow medical procedures to be done without pain; may involve loss of consciousness.

Base Units (BU)Base units assigned to specific anesthesia CPT codes derived from the ASA Anesthesia Relative Value Guide.

Conversion Factor (CF)Single unit rate used in calculation for anesthesia reimbursement.

Time Units (TU)An increment of fifteen (15) minutes where each 15-minute increment constitutes one time unit.

General/Local/RegionalGeneral: affects entire body with loss of consciousness; Local: loss of sensation in a limited surface area; Regional: loss of sensation of a particular region.

Operational thresholds

Thresholds

time unit calculationminutes reported / 15, rounded to the nearest tenth

field avoidance minimum base value>= 5 base units

separate session threshold>1 hour separation may allow second anesthesia to be eligible for separate reimbursement

Policy changes and review timeline

2010-07-06 to 2020-06-01historical_coding_updates

Numerous non-substantive wording and coding table updates and modifier clarifications implemented across 2010–2020 (historical coding/table edits, TEE/medication/qualification clarifications)

2020-11-25effective_date

Policy effective date established (reimbursement policy effective 11/25/2020)

2021-09-22biennial_reviewLatest

Biennial Review: definition section updated and language changes (last approval 09/22/2021)

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyProfessional Anesthesia Services (MA PPO)

Policy CodePolicy N/A

Change TypeBiennial review / clarifications

Effective DateNov 25, 2020

Next Review DateN/A

Key ActionProviders must document start and stop times in the medical record and report anesthesia minutes in one-minute increments; failure may result in claim rejection/denial.

SourceLink

On This Page

Payment cap for dual providers: When physician/anesthesiologist and non-physician anesthesia provider both provide services, total reimbursement will not exceed 100% of eligible amount for physician-only service

Laryngoscopy/bronchoscopy: Laryngoscopy and bronchoscopy procedures

Tube placement: Placement of endotracheal and naso-gastric tubes

Non-invasive monitoring: Placement and interpretation of non-invasive monitoring (ECG, temp, BP, pulse oximetry, CO2, capnography, mass spectrometry, vital capacity)

IV lines and meds: Placement of peripheral IV lines and administration of fluids, anesthetic, or other meds via IV

Venipuncture/transfusion: Venipuncture and transfusion

Pre/post op E/M: One-day preoperative E/M services and 10-day postoperative E/M services and related postoperative management within the 10-day period (applies to anesthesiologist or others in same anesthesia group)

01996 once per DOS and conflict with injection: Daily hospital management (CPT 01996) is eligible once per date of service following surgery; when billed with an anesthetic injection code (e.g., 62320-62327), only the injection code is eligible for reimbursement; modifiers will not override edits01996 eligible once per DOS; not allowed with injection on same DOS

QK/QX/QY reduction: When modifier QK, QX, or QY is appended to an applicable spinal/nerve injection code, a reimbursement percentage of 50% will apply50% reimbursement when QK/QX/QY appended

Denial for 01996 with physical status/qualifying: Anthem will deny daily hospital management code when billed with a physical status modifier or qualifying circumstance procedure codes