CurrentBlue Cross Blue Shield - MainePolicy C-09002

Anesthesia Services Professional Reimbursement Policy

Rules and guidelines for reimbursement of professional anesthesia services for Anthem Blue Cross and Blue Shield members (commercial), including coding, time reporting, modifiers, bundled vs separately reimbursable services, and special circumstances. Affects professional anesthesia providers and facilities billing Anthem commercial plans.

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyAnesthesia Services Professional Reimbursement Policy

Policy CodePolicy C-09002

Change TypeNo material change (historical edits noted)

Effective Date11/01/2024

Next Review Date

Key ActionEnsure services meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis.

SourceLink

POLICY UPDATE CHANGES

Accepted formatting changes on 03/08/2011; no wording changes made.

On 08/03/2010 the code range in Section 7c was changed to 93317 and note added about 93318 being a 0-superscript code and modifier 59 not overriding edit.

On 07/06/2010 base units source changed to ASA RVG; exception added that add-on codes 01953, 01968-01969 are separately reimbursed; system note about P3-P5 physical status modifiers.

12/14/2009: added instruction not to report 01996 with a physical status modifier or qualifying circumstances code and added related paragraph and footnote.

14pages

15minute divisor

5min base value

150%

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management allowance

Coverage Criteria and Billing Rules

Anesthesia reimbursement criteria

Key coverage rules and criteria for anesthesia reimbursement

Anesthesia services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis and the member's state of residence.

Services must be supported in the medical record and billed using industry-standard CPT/HCPCS codes.

Time reporting: Providers must report anesthesia services in one-minute increments; reported minutes are divided by 15 and rounded to the nearest tenth to produce time units.minutes/15

Claims with non-minute indicators may be rejected or denied.

Modifiers: Appropriate anesthesia, physical status (ASA) and servicing modifiers must be appended to anesthesia procedure codes; physical status modifier unit values must be appended when applicable.

Providers must place servicing modifiers in the primary modifier field as required; failure to append appropriate modifiers may result in denial.

ALL of the following

Exception: Add-on codes 01953, 01968, and 01969 are eligible for separate reimbursement when appropriately reported.
If documentation shows a separate subsequent operative session with more than one hour separation, the second anesthesia service may be considered separately reimbursable.

Qualifying circumstance CPT codes (99100, 99116, 99135, 99140) are always bundled and are not separately reimbursable.

These codes identify qualifying circumstances and will be denied as separate reimbursement.

Oral surgery: CPT anesthesia codes 00170 and 00176 for intraoral procedures are not eligible for reimbursement when reported with CDT codes; CDT anesthesia codes (eg D9211, D9248) are not eligible for separate reimbursement when reported with CPT.

When an oral surgeon reports CPT for the procedure and also provides anesthesia, Modifier 47 must be appended and no additional anesthesia reimbursement will be allowed.

Global reimbursement: The global anesthesia allowance includes pre-anesthesia evaluation through the time the anesthesia provider is no longer in personal attendance; services listed in policy (eg echocardiography for monitoring, inhalation treatments, placement of peripheral IVs, venipuncture, monitoring interpretation) are included and not separately reimbursable.

A one-day preoperative E/M and a 10-day postoperative E/M period for anesthesia-related E/M services applies to the anesthesia provider group.

Separate reimbursement exceptions: Anthem allows separate reimbursement for select procedures when distinct from the anesthesia service (eg central venous pressure line insertion, Swan-Ganz catheter, intra-arterial lines, select TEE when distinct and appended with appropriate modifier per NCCI, and nerve block injections for pain management).

Medications separately reported in a facility setting (eg Propofol) are considered included in the facility charge and are not separately reimbursable.

Post-payment actions: Anthem may recover or recoup payments, or deny/reject claims, if coding or billing guidelines are not followed; policies are subject to state/federal law and member benefit terms.

Policy may be updated periodically by the payer.

Postoperative Pain Management Coverage Criteria

Reimbursement conditions for postoperative pain management provided by anesthesiologists:

When postoperative pain management services are performed bilaterally, report the unilateral code once with modifier 50 using the applicable base value for the unilateral service.

Applicable code ranges include 62320-62327 and 64400-64450.

Postoperative management services performed by an anesthesiologist, such as an injection or catheter insertion into the epidural space or a major nerve, are eligible for separate reimbursement and time units do not apply.

These services are considered surgical-type services and are reimbursed separately from the primary anesthesia code.

The management code for postoperative pain management will be considered one surgical service and is eligible for reimbursement equal to 150% of the allowance for the code.

This reflects the policy's reimbursement allowance for the management code relative to the code allowance.

CPT 01996 (daily hospital management of epidural/subarachnoid continuous drug administration) is eligible for reimbursement once per date of service following the surgery date; however, when 01996 is reported with an anesthetic injection code (eg 62320-62327) only the injection code is eligible for reimbursement and modifiers will not override this edit.

Anesthesia coverage and billing guidance

Billing and coding rules, definitions, and historical amendments relevant to anesthesia reimbursement.

Do not report CPT 01996 with a physical status modifier or qualifying circumstances code.

This instruction was added in the 12/14/2009 policy history and is an explicit billing clarification.

Transesophageal echocardiography (TEE) coding: code range adjustments include 93317; CPT 93318 is noted as a 0-superscript code and modifier 59 will not override edits for those codes when incidental to anesthesia monitoring.

TEE must be reported as distinct and independent with the appropriate modifier per NCCI to be eligible for separate reimbursement.

Add-on codes 01953 and 01968-01969 are separately reimbursed when appropriately reported.

This exception was clarified in policy history (07/06/2010) and reflected in multiple sections of the policy.

Definitions relevant to reimbursement calculations: Base Units (BU) are derived from the ASA Anesthesia Relative Value Guide (RVG); Time Units (TU) are increments of 15 minutes; Conversion Factor (CF) is geographic-specific and varies by locality.

Codes, Units, and Reporting

Relevant code groups and examplesmixedCovered

Anesthesia CPT codes	Use anesthesia codes; append physical status and servicing modifiers as applicable; proper use of modifiers required.
99100, 99116, 99135, 99140	Qualifying circumstance CPT codes (bundled).
00170, 00176	CPT anesthesia codes for intraoral procedures not eligible when reported with CDT.
D9211, D9248, D9201, D9248	CDT anesthesia codes for oral surgery; billing rules provided.
62320-62327, 64400-64450	Postoperative pain management codes eligible for separate reimbursement.

Postoperative pain management and related codesCPTCovered

62320-62327	Spinal injection codes referenced under postoperative pain management
64400-64450	Major peripheral nerve and other injection codes referenced
01996	Daily hospital management of epidural/subarachnoid continuous drug administration

Anesthesia and related codes referenced in historyCPT | mixedCovered

93317	TEE code referenced in policy history (code range adjusted)
93318	Noted as a 0-superscript code; modifier 59 will not override edit
01953	Add-on code noted as separately reimbursed
01968	Add-on code noted as separately reimbursed
01969	Add-on code noted as separately reimbursed
01996	Should not be reported with a physical status modifier or qualifying circumstances code

inv-07: Time reporting increment

Reporting incrementReport anesthesia services in one-minute increments; minutes divided by 15 and rounded to the nearest tenth to produce time units; start/stop times must be documented.

Calculation methodNumber of minutes reported ÷ 15, rounded to the nearest tenth to provide a unit of measure.

Claim validationAnesthesia claims submitted with an indicator other than minutes may be rejected or denied.

Interrupted anesthesiaAnesthesia time can be counted in blocks if there is an interruption, provided counted time reflects continuous anesthesia services.

inv-08: 01996 frequency

01996 frequency

Provider Responsibilities and Billing Notices

Prior Authorization

Authorization and Medical Necessity

These services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis. Services that do not meet the member's benefit plan requirements, prior authorization, or medical necessity criteria may be denied or subject to recoupment.

Billing Rule

Postoperative Pain Management Billing Rules

Postoperative pain management services (for example, an epidural or major nerve injection or catheter insertion performed by an anesthesiologist) are eligible for separate reimbursement in addition to the primary anesthesia code. When performed bilaterally, report the unilateral code once with modifier 50. Time units do not apply to postoperative pain management; the management service is considered one surgical service and may be eligible for reimbursement at 150% of the allowance for the code when applicable. The appropriate modifier must be appended to indicate a distinct procedural service.

Key Definitions and Units

inv-13: Anesthesia time

DefinitionAnesthesia time starts with preparation of the member for administration of anesthesia and stops when the anesthesia provider is no longer in personal attendance.

Reporting precisionReported in one-minute increments with documented start and stop times in the medical record.

Interrupted servicesTime may be counted in blocks for interruptions as long as the counted time reflects continuous anesthesia services provided.

inv-14: Physical status modifier

PurposePhysical status modifiers identify the patient’s physical condition per ASA and indicate added complexity to the anesthesia service.

Unit valuesAnthem follows ASA recommendations that unit values are assigned to physical status modifiers for additional reimbursement when appended to the base anesthesia code.

Policy Background and Revision History

2011-03-08administrative

Accepted formatting changes to eliminate mark‑ups; no wording changes made.

2010-10-05review

Review approved after legal review with minor grammatical and wording tweaks and editorial adjustments to several sections.

2010-08-03revision

Code range in Section 7c was changed to include 93317; note added that 93318 is a 0‑superscript code and that modifier 59 will not override the edit.

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyAnesthesia Services Professional Reimbursement Policy

Policy CodePolicy C-09002

Change TypeNo material change (historical edits noted)

Effective Date11/01/2024

Next Review Date

Key ActionEnsure services meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis.

SourceLink

On This Page

01996: once per date of service

01996 is excluded when billed with specified injection codes; modifiers cannot override edits.

These definitions underlie calculation of anesthesia reimbursement (BU + TU + CF).

Policy use and applicability: The policy is subject to federal and state laws and the member's benefit terms; the payer reserves the right to review and update policies periodically.

Policy history documents administrative and substantive changes (2009–2011).

CPT 01996 (daily hospital management) is eligible once per date of service following the surgery date.

Exclusion with injectionsWhen 01996 is reported with an anesthetic injection code (e.g., 62320-62327), only the injection code is eligible for reimbursement; modifiers will not override edits.

Distinct procedural serviceAppropriate modifier must be appended to indicate a distinct procedural service when performed in addition to the primary anesthesia code.

inv-09: Time unit increment

Time unit definitionTime Units (TU) are increments of fifteen (15) minutes.

Use in reimbursementMinutes reported are converted to Time Units by dividing by 15 and rounding to nearest tenth as described under time reporting.

Relation to BU/CFTime Units are used with Base Units (BU) and the Conversion Factor (CF) to calculate anesthesia reimbursement.

Applicable codes/ranges: 62320-62327, 64400-64450

Billing Rule

Billing Clarification

Do not report CPT 01996 (daily hospital management of epidural or subarachnoid continuous drug administration) with a physical status modifier or qualifying circumstance procedure codes to override edits. CPT 01996 is payable once per date of service following the surgery date for postoperative pain management when reported alone. However, when CPT 01996 is reported with an anesthetic injection code (e.g., 62320-62327), only the injection code is eligible for reimbursement — modifiers will not override the edits. The Health Plan will deny daily hospital management of epidural or subarachnoid continuous drug administration when billed in combinations that are disallowed by claim edits.

CPT 01996 — daily hospital management of epidural or subarachnoid continuous drug administration
If CPT 01996 is billed with injection codes 62320-62327, only the injection code will be reimbursed; modifiers will not override edits.

Billing positionModifiers identifying who performed the anesthesia must be billed in the primary modifier field to receive appropriate reimbursement; claims without appropriate modifiers may be denied.

inv-15: Postoperative pain management services

Separate reimbursement allowancePostoperative pain management services (e.g., epidural/major nerve injections or catheter insertions) by an anesthesiologist are eligible for separate reimbursement; time units are not applicable.

Management code reimbursementThe management code is considered one surgical service and eligible for reimbursement equal to 150% of the allowance for the code.

Bilateral reportingWhen performed bilaterally, report the unilateral code once with modifier 50 using the applicable base value for the unilateral.

01996 exclusion with injectionsCPT 01996 is reimbursable once per date of service after surgery but when reported with injection codes (e.g., 62320-62327) only the injection code is eligible; modifiers will not override edits.

inv-16: Base Units (BU)

DefinitionBase Units (BU) are assigned to a specific anesthesia CPT code and are derived from the American Society of Anesthesiologists (ASA) Anesthesia Relative Value Guide (RVG).

Role in paymentBU are combined with Time Units (TU) and the Conversion Factor (CF) to determine anesthesia reimbursement.

SourcePolicy notes base units are derived from the ASA RVG (per policy history and definitions).

inv-17: Time Units (TU)

IncrementTime Units (TU) are increments of fifteen (15) minutes.

Conversion from minutesMinutes reported are divided by 15 and rounded to the nearest tenth to yield Time Units for reimbursement calculations.

Use with BU/CFTime Units are applied with Base Units and the Conversion Factor to calculate the payment amount for anesthesia services.

inv-18: Conversion Factor (CF)

DefinitionConversion Factor (CF) is a geographic-specific amount that varies by the locality where the anesthesia is administered.

FunctionCF is multiplied with the sum of Base Units and Time Units to determine the anesthesia reimbursement amount.

Local variationCF varies by locality and is applied per payer locality rules.

inv-19: Anesthesia (General/Regional/Local)

General anesthesiaDrug-induced loss of consciousness during which patients are not arousable, even by painful stimulation.

Regional anesthesiaDelivery of anesthetic medication at a specific level of the spinal cord and/or to peripheral nerves when loss of consciousness is not desired but sufficient analgesia and loss of voluntary and involuntary movement is required.

Local anesthesiaLoss of sensation in a limited and superficial area of the body.

2010-07-06revision

Base units source changed to the ASA RVG and exception added that add‑on codes 01953, 01968, 01969 are separately reimbursed; system note added about P3‑P5 physical status modifiers.

2009-12-14revisionLatest

Instruction added that CPT 01996 must not be reported with a physical status modifier or qualifying circumstances code; related paragraph and footnote were added.