CurrentBlue Cross Blue Shield - MainePolicy N/A

Professional Anesthesia Services

Defines reimbursement and billing rules for professional anesthesia services for AMH Health (Blue Cross Blue Shield - Maine) including time reporting, modifier usage, multiple procedure allowance, obstetrical anesthesia limits, separately reimbursable services, and nonreimbursable items.

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyProfessional Anesthesia Services

Policy CodePolicy N/A

Change TypeClarified (administrative)

Effective DateJan 1, 2020

Next Review Date

Key ActionProviders must report anesthesia services in minutes; start and stop times must be documented in the member's medical record.

SourceLink

POLICY UPDATE CHANGES

Biennial review approved 11/06/20: minor administrative updates; added anesthesia modifier initial approval and effective date 01/01/20 grid.

300Obstetrical epidural time limit (minutes)

6Separately reimbursable services listed

6Anesthesia modifiers described

Policy overview

AMH Health's Professional Anesthesia Services reimbursement guide explains claims submission and the basis for payment when services are covered by a member's AMH Health (Blue Cross Blue Shield - Maine) benefit plan. Reimbursement follows CMS-based formulas and time increments, using base units, time units (each 15 minutes per time unit), and a geographic conversion factor. Providers must report anesthesia services in minutes with documented start and stop times in the medical record; anesthesia time begins with preparation of the member for anesthesia and ends when the anesthesia provider is no longer in personal and continuous attendance. Claims must use proper CPT/HCPCS/revenue codes and applicable anesthesia modifiers billed in the primary modifier field, and required documentation must be provided to support billed services and any disputes (for example, obstetrical epidural time beyond 300 minutes).

Coverage and clinical requirements

General reimbursement and documentation requirements

Reimbursement allowed when ALL of the following are met:

Service is rendered by professional providers for covered members and not excluded by provider, state, federal or CMS contracts

Reimbursement is based on the CMS reimbursement formula for allowance and time increments

Proper use of applicable anesthesia modifiers; modifiers identifying who performed the anesthesia must be billed in the primary modifier field

Providers must report anesthesia services in minutes; 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 and continuous attendance

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

Multiple anesthesia procedures

When multiple procedures occur during the same anesthesia episode:

Reimbursement is based on the anesthesia procedure with the highest base unit value

Reimbursement is based on the overall anesthesia time for all procedures

Separately reimbursable services provided in conjunction with anesthesia

AMH Health allows separate reimbursement (based on contracted/negotiated rate) for the following services when provided with anesthesia:

Swan-Ganz catheter insertion

Reimbursement based on contracted/negotiated rate; no reporting of time

Central venous pressure line insertion

Reimbursement based on contracted/negotiated rate; no reporting of time

Intra-arterial lines

Reimbursement based on contracted/negotiated rate; no reporting of time

Emergency intubation (must be provided in conjunction with the anesthesia procedure)

Reimbursement based on contracted/negotiated rate; no reporting of time

Critical care visits

Obstetrical neuraxial epidural anesthesia

Coverage for epidural analgesia during labor and delivery:

Reimbursed for up to 300 minutes by either the delivering physician or a qualified provider other than the delivering physician based on physical presence time300 minutes

Providers must submit additional documentation upon dispute for consideration of reimbursement of time in excess of 300 minutes

Reimbursement for a qualified provider other than the delivering physician includes catheter insertion and anesthesia administration per the allowance calculation

Nonreimbursable anesthesia services

AMH Health does NOT reimburse the following anesthesia-related services:

Use of patient status modifiers or qualifying circumstance codes denoting additional complexity levels

Anesthesia consultations on the same date as surgery or the day-to-surgery if part of the preoperative assessment

Anesthesia services performed for noncovered procedures, including services considered not medically necessary, experimental and/or investigational

Anesthesia services by the provider performing the basic procedure (except delivering physician providing continuous epidural analgesia)

Local anesthesia considered incidental to the surgical procedure

Modifiers and code guidance

Anesthesia modifiers table (informational with reimbursement rules)mixed

AA	Anesthesia services personally performed by the anesthesiologist. Reimbursed at 100% of applicable fee schedule or contracted/negotiated rate.
AD	Medical supervision by a physician: more than four concurrent anesthesia procedures. Reimbursed at 100% of the applicable fee schedule or contracted/negotiated rate for up to three base units for anesthesiologists.
QK	Medical direction of two, three, or four concurrent anesthesia procedures involving qualified individuals. Reimbursed at 50% of allowance; reimbursement based on 50% of applicable fee schedule or contracted/negotiated amount.
QX	Qualified nonphysician anesthetist with medical direction by a physician. Reimbursed at 50% of applicable fee schedule or contracted/negotiated amount.
QY	Anesthesiologist medically directs one CRNA. Reimbursed at 50% of applicable fee schedule or contracted/negotiated amount.
G	CRNA without medical direction by a physician. Reimbursed at 100% of applicable fee schedule or contracted/negotiated amount.
23	Procedure must be done under general anesthesia due to unusual circumstances. Reimbursed at 100% of applicable fee schedule or contracted/negotiated rate; does not change reimbursement but substantiates billing anesthesia when not usually appropriate.
47	Denotes regional or general anesthesia services provided by the surgeon performing the medical procedure. Not allowed for reimbursement (other than obstetrical as noted).

Billing Rule

Use appropriate primary anesthesia modifier

Modifiers identifying who performed the anesthesia service must be billed in the primary modifier field. Codes affected: AA, AD, QK, QX, QY, 23, 47. Claims submitted without the appropriate primary modifier will be denied.

AA
AD
QK
QX
QY
23
47
Must be billed in the primary modifier field; claims submitted without appropriate modifier will be denied.

Billing, documentation, and denial risks

Billing Rule

Report anesthesia services in minutes and document times

Providers must report anesthesia services in minutes and document start and stop times in the member's medical record. Anesthesia time begins with preparation of the member for administration of anesthesia and ends when the anesthesia provider is no longer in personal and continuous attendance. Claims submitted with an indicator other than minutes may be rejected or denied.

Documentation Required

Documentation for obstetrical anesthesia beyond 300 minutes

For neuraxial epidural analgesia during labor and delivery, reimbursement is allowed for up to 300 minutes. Providers must submit additional documentation upon dispute for consideration of reimbursement for time in excess of 300 minutes.

Providers must submit additional documentation upon dispute for consideration of reimbursement of time in excess of 300 minutes.

Billing Rule

Multiple procedures reimbursement calculation

When multiple anesthesia procedures occur during the same anesthesia episode, reimbursement is based on the anesthesia procedure with the highest base unit value and the overall anesthesia time across all procedures.

Denial Risk

Nonreimbursable services risk

AMH Health does not reimburse certain anesthesia-related services. Claims for the listed nonreimbursable services will be denied.

Standby anesthesia
Anesthesia consultations on the same date as surgery or the day‑of surgery if part of the preoperative assessment
Anesthesia by the operating surgeon except obstetrical (Modifier 47)

OpenPayer

Professional Anesthesia Services

Policy overview

Coverage and clinical requirements

Modifiers and code guidance

Billing, documentation, and denial risks

Key terms

Policy changes and review timeline