ModifiedBlue Cross Blue Shield - MainePolicy C-09002

Anesthesia Services - Professional

Reimbursement rules for professional anesthesia services (reporting, modifiers, time, included/excluded services, and special circumstances) affecting professional anesthesia providers billing Blue Cross Blue Shield - Maine commercial plans.

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyAnesthesia Services - Professional

Policy CodePolicy C-09002

Change TypeRevisions and clarifications to modifiers, coding, and definitions

Effective DateApr 1, 2026

Next Review DateN/A

Key ActionReport anesthesia time in one-minute increments and document start/stop times in the medical record; use applicable anesthesia modifiers in the primary modifier field.

SourceLink

POLICY UPDATE CHANGES

Updated title of policy from Professional Anesthesia Services and removed modifiers G8, G9 and QS from policy; updated Related Coding section and modifier QZ reimbursement to be based on the fee schedule.

Updated Definitions section by revising multiple descriptions.

Added information that modifiers AA, AD, QK, QX, QY, or QZ must be listed in the first modifier field to ensure correct pay percent for anesthesia services.

Updated language to state that medication reported by a professional provider in a facility place of service is not reimbursed separately.

Updated 'Pain Management' language to include the term 'postoperative' to reflect concern with postoperative pain management services.

1-mintime reporting precision

15-mintime units divisor

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Coverage Criteria for Professional Anesthesia Services

COVERAGE CRITERIA — Criteria and rules for reimbursement of professional anesthesia services, including reporting, modifiers, multiple procedures, included/excluded services, and special circumstances.

Criteria and rules for reimbursement of professional anesthesia services, including reporting, modifiers, multiple procedures, included/excluded services, and special circumstances.

ALL of the following

Anesthesia services are reimbursed based on the American Society of Anesthesiologists (ASA) anesthesia formula unless otherwise noted in an exemption.
Services involving administration of anesthesia must be reported using anesthesia procedure codes and, when applicable, a physical status modifier and/or servicing modifier. Modifiers identifying who performed the anesthesia must be billed in the primary modifier field to receive appropriate reimbursement. Claims submitted without the appropriate modifier will be denied.
Time reporting: Providers must report anesthesia time in one-minute increments and note minutes in the units field. Reimbursement is calculated by dividing reported minutes by 15 and rounding to the nearest tenth to produce units. Anesthesia claims submitted with an indicator other than minutes may be rejected or denied. Start and stop times must be documented in the member's medical record. Anesthesia time starts with preparation of the member for administration of anesthesia and stops when the anesthesia provider is no longer in personal attendance. Interrupted anesthesia may be counted in blocks if continuous anesthesia services are provided during counted time.
Operational: retain minute-level documentation in the medical record.
Total reimbursement for anesthesia services provided by a physician/anesthesiologist and a non-physician anesthesia provider will not exceed 100% of the eligible amount that would be allowed had the service been provided by only the physician/anesthesiologist.
Multiple procedures: When anesthesia services are provided for multiple surgical procedures, report only the anesthesia procedure code for the most complex service. Base units apply only to the primary procedure; secondary procedures are not reimbursed separately. If two separate anesthesia codes are reported, the lesser will be denied (Exception: add-on codes 01953, 01968, 01969 are eligible for separate reimbursement). If the anesthesia record documents a separate subsequent operative session with >1 hour separation from the initial anesthesia, the second service may be eligible for separate reimbursement.
Field avoidance and unusual positioning: Procedures around the head, neck, or shoulder girdle requiring field avoidance, or procedures requiring a position other than supine or lithotomy, have a minimum base value of 5 regardless of a lesser assigned base value. Unusual positioning is not eligible for additional reimbursement even when reported with modifier 22.
Services included in global reimbursement: Global anesthesia reimbursement includes all procedures integral to administration of anesthesia from initial pre-anesthesia evaluation through the time the anesthesiologist or qualified provider in the same group is no longer in personal attendance. Included (not eligible for separate reimbursement) examples: daily hospital management of patient-controlled analgesia; echocardiography; electroencephalogram; inhalation treatments; laryngoscopy and bronchoscopy; placement and interpretation of non-invasive monitoring (eg, ECG, temperature, BP, pulse oximetry, capnography, mass spectrometry, vital capacity); placement of endotracheal and nasogastric tubes; placement of peripheral IV lines and administration of fluids/medications; venipuncture and transfusion.
Pre/postoperative E/M and nerve blocks: One-day preoperative E/M and 10-day postoperative E/M services (including E/M follow-up and postoperative pain management related to the surgical episode) are considered included in the global anesthesia reimbursement for the anesthesiologist or qualified provider who performed the general anesthesia and other providers in the same anesthesia group. Nerve block injections for pain management are eligible for separate reimbursement.
Medication reporting in facility settings: When an anesthesia professional separately reports a medication in a facility setting, the medication is not eligible for separate reimbursement even when reported with an unclassified or unspecified drug code (eg, J3490). The provision of any medication, including Propofol, is considered included under the facility's charge.
Services eligible for separate reimbursement when performed with anesthesia: Swan-Ganz catheter insertion; central venous pressure line insertion; intra-arterial lines; transesophageal echocardiography (TEE). For TEE (CPT codes 93312-93317), if performed as a distinct and independent procedure from anesthesia, append the appropriate modifier to the TEE code to be eligible for separate reimbursement. TEE monitoring codes (eg, 93318) or codes for guidance of transcatheter intracardiac/great vessel structural interventions (eg, 93355) will follow NCCI edit logic and are considered incidental; a bypass modifier will not override.
Postoperative pain management: Postoperative pain management services by an anesthesiologist (eg, injection or catheter insertion into epidural space or major nerve) are eligible for separate reimbursement and time units do not apply. Applicable codes/ranges include 62320-62327 and 64400-64450. When performed bilaterally, report the unilateral code once with modifier 50; the allowance will be 150% of the unilateral code. An epidural or major nerve injection or catheter insertion performed for postoperative pain management before, during, and/or after the surgical procedure is eligible in addition to the primary anesthesia code; append the appropriate modifier to indicate a distinct procedural service. The daily hospital management code for epidural/subarachnoid continuous drug administration (CPT 01996) 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; modifiers will not override edits. The health plan will deny daily hospital management codes when billed with a physical status modifier or qualifying circumstance procedure codes.

Administrative coverage and billing rules — Administrative coverage positions and billing rules reflected in the policy history and disclaimer.

Administrative coverage positions and billing rules reflected in the policy history and disclaimer.

ALL of the following

Policy history: updates to coding, language clarifications, and scope (including statements that medications reported by a professional provider in a facility place of service are not reimbursed separately). Review history may reflect non-substantive edits (punctuation, grammar) and changes in included examples; refer to policy history for historical context.
Billing and submission requirements: Use proper billing and submission guidelines and industry-standard, compliant codes (CPT, HCPCS, revenue codes). Codes billed must be fully supported in the medical record and/or office notes. Failure to follow coding/billing guidelines or current reimbursement policies may result in claim rejection or denial, recovery/recoupment of payment, or application of mandates in provider, state, federal, or CMS contracts.
Authorization and medical necessity: Determination that a service is covered under a member's benefit plan is not a guarantee of reimbursement. Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis and the member's state of residence.

Coding, Modifiers, and Related Billing Rules

Qualifying circumstance codesCPTNot Covered

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.
99135	Anesthesia complicated by utilization of controlled hypotension.
99140	Anesthesia complicated by emergency conditions.

Oral surgery anesthesia coding interactionmixed

D9211-D9248	CDT codes for anesthesia for oral surgery.
00170-00176	CPT anesthesia codes for intraoral procedures (not eligible when reported with CDT).

Postoperative pain management codesCPT

62320-62327	Epidural or major nerve injections for postoperative pain management (eligible for separate reimbursement).
64400-64450	Major nerve block codes eligible for separate reimbursement for postoperative pain management.
01996	Daily hospital management of epidural/subarachnoid continuous drug administration (eligible once per date of service but limited when billed with injection codes).

Modifier placementModifierCovered

AA, AD, QK, QX, QY, QZ

Anesthesia-related pay percent modifiers required in first modifier field to ensure correct pay percent.

Facility drug billingHCPCSNot Covered

J3490 (example)

Unclassified drug code; facility-provided medications billed by anesthesia provider in facility not eligible for separate reimbursement.

Time units rounding - inv-08: Minutes divided by 15 and rounded to nearest tenth.

Rounding ruleMinutes reported are divided by 15 and the result is rounded to the nearest tenth to calculate time units for reimbursement.

Reporting precisionProviders must report anesthesia time in one-minute increments and record start/stop times in the medical record.

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

Counting interrupted timeAnesthesia time may be counted in blocks if interrupted, provided counted time represents continuous anesthesia services.

Base units - inv-09: Base units derived from ASA RVG (per historical notes).

Provider Billing Actions and Documentation Requirements

Billing Rule

Billing and Reporting Requirements

Report anesthesia services using the ASA anesthesia formula when applicable. Use anesthesia procedure codes and, when appropriate, append physical status and servicing modifiers. Document qualifying circumstances, unusual positioning, and any additional factors in the medical record.

Use ASA anesthesia formula for reimbursement unless an exemption applies.
Report services with anesthesia codes and appropriate physical status and servicing modifiers.
Document qualifying circumstances and unusual positioning in the medical record.

Documentation Required

Time Reporting

Report anesthesia time in one-minute increments and enter minutes in the units field. For reimbursement, divide total minutes by 15 and round to the nearest tenth to obtain billing units. Start and stop times must be documented in the member's medical record. Anesthesia time begins with preparation of the member for anesthesia and ends when the anesthesia provider is no longer in personal attendance. Time may be counted in blocks if interrupted, provided only continuous anesthesia service time is included.

Definitions and Glossary

inv-14: Base Units

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

PurposeUsed as the procedural component in the ASA anesthesia formula to calculate professional anesthesia reimbursement.

ApplicationApplied per primary anesthesia CPT code; base units for secondary lesser procedures are generally not used except in specified exceptions.

inv-15: Conversion Factor

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

Role in paymentConversion Factor is multiplied by the sum of base units and time units (and any adjustments) to determine reimbursement amount.

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyAnesthesia Services - Professional

Policy CodePolicy C-09002

Change TypeRevisions and clarifications to modifiers, coding, and definitions

Effective DateApr 1, 2026

Next Review DateN/A

Key ActionReport anesthesia time in one-minute increments and document start/stop times in the medical record; use applicable anesthesia modifiers in the primary modifier field.

SourceLink

On This Page

Billing Rule

Modifier Usage and Payment Cap

Append anesthesia modifiers that identify the performer in the primary modifier field to receive correct reimbursement. Claims submitted without the appropriate anesthesia modifier may be denied. When both a physician/anesthesiologist and a non-physician anesthesia provider furnish services for the same anesthesia event, combined reimbursement will not exceed 100% of the eligible amount that would be allowed if only the physician/anesthesiologist provided the service. Refer to the related coding section for specific anesthesia modifiers.

Modifiers identifying who performed the anesthesia must be billed in the primary modifier field.
Claims without the appropriate anesthesia modifier may be denied.
Combined physician and non-physician anesthesia reimbursement capped at 100% of the physician-only eligible amount.

Prior Authorization

Authorization and Medical Necessity

Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis and to the member's state of residence. Use proper CPT, HCPCS, and/or revenue codes and ensure all billed services are fully supported in the medical record and/or office notes. Failure to follow coding, billing, or reimbursement policies may result in claim rejection, denial, or recovery/recoupment of payment.

Services require appropriate prior authorization and must meet medical necessity criteria for the procedure and diagnosis.
Bill with industry-standard CPT, HCPCS, and/or revenue codes supported in the medical record.
Noncompliance with coding/billing guidelines may lead to rejection, denial, or payment recovery.

inv-18: Facility medication reimbursement

Facility drug chargesMedication reported by a professional provider in a facility place of service is not eligible for separate reimbursement; such drug charges are considered part of the facility's billing.

ExamplePolicy history specifies Propofol and other medications provided in the facility are included in facility charges and not separately reimbursed.

Unclassified drug codesUse of unclassified/unspecified drug codes reported by a professional in a facility does not make the drug charge separately reimbursable.