CurrentBlue Cross Blue Shield - MainePolicy N/A

Professional Anesthesia Services PDF. Opens in a new window

Defines Anthem Medicare Advantage reimbursement rules for professional anesthesia services including time reporting, modifiers, multiple procedures, obstetrical anesthesia limits, services reimbursed in conjunction, and non-reimbursable items. Applies to participating providers and facilities unless overridden by contracts or CMS/state mandates.

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyProfessional Anesthesia Services PDF. Opens in a new window

Policy CodePolicy N/A

Change TypeBiennial review / administrative updates

Effective Date11/06/20

Next Review Date

Key ActionProviders must report anesthesia services in minutes and document start and stop times in the member's medical record; failure to report in minutes may result in claim rejection or denial.

SourceLink

POLICY UPDATE CHANGES

Minor administrative updates to policy body and addition of anesthesia modifier grid.

Policy language updated on 10/03/18 and template updated 01/03/17.

Initial committee approval and effective 01/01/15.

15Time unit minutes

300Obstetrical epidural time limit (minutes)

8Anesthesia modifiers listed

Policy summary

Anthem Medicare Advantage professional anesthesia reimbursement policies guide accurate claims submission and define the basis for payment when anesthesia services are covered by a member's benefit plan. Reimbursement follows the CMS reimbursement formula for the allowance and time increments and uses regional conversion factors where applicable. Providers must report anesthesia services in minutes with documented start and stop times and use industry-standard codes and applicable anesthesia modifiers to receive appropriate payment. These rules apply to participating providers and facilities unless overridden by provider, state, federal or CMS mandates or contractual requirements.

Reimbursement criteria and exclusions

General Reimbursement Conditions

Anthem Medicare Advantage reimbursement policies guide accurate claims submission and outline basis for reimbursement when services are covered by a member's plan. Reimbursement follows CMS formulas and regional conversion factors; policies may be superseded by provider/state/federal or CMS mandates.

ALL of the following

Service is covered under the member's benefit plan and meets authorization and medical necessity guidelines appropriate to the procedure and diagnosis
Services are reported with industry-standard compliant codes (CPT, HCPCS, revenue codes) and the billed codes are fully supported in the medical record/office notes
Providers must report anesthesia services in minutes; anesthesia time documented as start (preparation for administration) and stop (provider no longer in personal and continuous attendance)
Reimbursement is based on the CMS reimbursement formula for allowance and time increments and proper use of applicable modifiers

Multiple Anesthesia Procedures

When multiple procedures occur during anesthesia:

ALL of the following

Reimbursement is based on the anesthesia procedure with the highest base unit value
Overall anesthesia time for all procedures is used in reimbursement calculation

Obstetrical Neuraxial Epidural Anesthesia

Covered when ALL of the following are met:

ALL of the following

Provided in conjunction with labor and delivery
Time-based reimbursement allowed for up to 300 minutes by either the delivering physician or a qualified provider other than the delivering physician based on the time the provider is physically present with the member<= 300 minutes
If exceeding 300 minutes
- Providers must submit additional documentation upon dispute for consideration of reimbursement of time in excess of 300 minutes
Reimbursement method

Nonreimbursable Anesthesia Services / Items

The following are not reimbursed:

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

Anesthesia consultations on the same date as surgery or the day prior 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 for a delivering physician providing continuous epidural analgesia

Local anesthesia considered incidental to the surgical procedure

Code lists & modifiers

Anesthesia Modifiers (informational with reimbursement rules)Modifier

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 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.
QX	Qualified nonphysician anesthetist with medical direction by a physician; Reimbursed at 50% of allowance.
QY	Anesthesiologist medically directs one CRNA; Reimbursed at 50% of allowance.
QZ	CRNA without medical direction by a physician; Reimbursed at 100% of allowance.
23	Denotes a procedure that must be done under general anesthesia due to unusual circumstances although normally done under local or no anesthesia; Reimbursed at 100% of procedure rate; substantiates anesthesia billing where not usually appropriate.
47	Denotes regional or general anesthesia services provided by the surgeon performing the medical procedure; Anthem does not allow reimbursement of anesthesia services by the provider performing the medical procedure (other than obstetrical).

Billing, documentation & denial risks

Documentation Required

Report anesthesia time in minutes with start/stop times

Providers must report anesthesia services in minutes and document start and stop times in the member's medical record. Time starts with preparation for administration and stops 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
Failure to document start and stop times may lead to claim rejection or denial

Billing Rule

Use appropriate anesthesia modifiers in primary modifier field

Anesthesia modifiers identifying who performed the anesthesia service must be billed in the primary modifier field to receive appropriate reimbursement; claims submitted without the appropriate modifier will be denied.

Affected modifiers: AA, AD, QK, QX, QY, QZ, 23, 47

Documentation Required

Documentation for obstetrical epidural >300 minutes

For neuraxial epidural anesthesia provided in conjunction with labor and delivery, time-based 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.

Billing Rule

Multiple procedures reimbursement method

When multiple anesthesia procedures occur during the same anesthetic, reimbursement is based on the anesthesia procedure with the highest base unit value while the overall anesthesia time for all procedures is used in the reimbursement calculation.

Denial Risk

Nonreimbursable items lead to denial

Certain anesthesia-related items and services are not reimbursed and claims for those items may be denied if billed. Examples include standby anesthesia, local anesthesia considered incidental to the surgical procedure, and anesthesia performed by the provider performing the basic procedure (except for a delivering physician providing continuous epidural analgesia).

Modifier/code example: 47 (anesthesia by the surgeon — not reimbursed except obstetrical)

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyProfessional Anesthesia Services PDF. Opens in a new window

Policy CodePolicy N/A

Change TypeBiennial review / administrative updates

Effective Date11/06/20

Next Review Date

Key ActionProviders must report anesthesia services in minutes and document start and stop times in the member's medical record; failure to report in minutes may result in claim rejection or denial.

SourceLink

On This Page

OpenPayer

Professional Anesthesia Services PDF. Opens in a new window

Policy summary

Reimbursement criteria and exclusions

Services reimbursed separately with no anesthesia time reporting

Code lists & modifiers

Billing, documentation & denial risks

Definitions

Policy changes & timeline