CurrentBlue Cross Blue Shield - NevadaPolicy ABCBSRP-0124-21

Professional Anesthesia Services

Reimbursement policy governing professional anesthesia services for Anthem Blue Cross Blue Shield Medicare Advantage members, including billing units (minutes), modifiers, multiple-procedure rules, obstetrical anesthesia limits, and reimbursable/nonreimbursable services. Applies to participating providers and facilities unless superseded by contracts or CMS/state mandates.

Policy Summary

PayerBlue Cross Blue Shield - Nevada

PolicyProfessional Anesthesia Services

Policy CodePolicy ABCBSRP-0124-21

Change TypeAdministrative/template updates (no material clinical changes)

Effective DateNov 6, 2020

Next Review Date

Key ActionReport anesthesia services in minutes and ensure start/stop times and continuous attendance are documented; bill appropriate anesthesia modifiers in the primary modifier field or claims may be denied.

SourceLink

POLICY UPDATE CHANGES

Minor administrative updates to policy body and added anesthesia modifier (biennial review effective 11/06/20).

Policy template updates on 10/03/18 and 01/03/17 noted in history.

Initial committee approval and effective 01/01/15 recorded in history.

9Anesthesia modifiers provided

300 minObstetrical epidural reimbursed up to

15 minTime unit increment

Payer: Anthem Blue Cross Blue Shield Medicare Advantage. This reimbursement policy (Policy ABCBSRP-0124-21, status CURRENT) governs professional anesthesia services and outlines billing, documentation and reimbursement requirements consistent with CMS guidelines.

Purpose and scope: policy provides high-level guidance for reimbursement of professional anesthesia services for Anthem BCBS Medicare Advantage members including the reimbursement formula (CMS-based), required reporting of anesthesia time in minutes, applicable base units and time units (15-minute increments), and required use of anesthesia modifiers.

Applicability: applies to participating providers and facilities unless superseded by provider contract terms or state, federal or CMS mandates; non-contracting providers who accept Medicare assignment are reimbursed according to original Medicare rates where applicable.

Key topics summarized: billing units in minutes and documentation of start/stop times and continuous attendance; modifier requirements and reimbursement impacts; multiple-procedure rules (allowance based on the anesthesia procedure with the highest base unit and total anesthesia time); obstetrical neuraxial epidural limits (separate reimbursement up to 300 minutes, with documentation required for time in excess); and lists of separately reimbursable versus nonreimbursable anesthesia-related services.

Key facts

Effective date11/06/20

Last review11/06/20

Next review

Policy numberABCBSRP-0124-21

StatusCURRENT

SubjectProfessional Anesthesia Services reimbursement

Obstetrical epidural time limitReimbursed up to 300 minutes; additional time requires documentation for dispute

Time unit15-minute increments (each 15-minute increment constitutes one time unit)

Reimbursement & coverage requirements

General Reimbursement Requirements

Anesthesia services are reimbursed when billed and documented per requirements:

Minutes reporting requirement: Providers must report anesthesia services in minutes; anesthesia claims submitted with an indicator other than minutes may be rejected or denied.
Start/stop documentation: Start and stop times must be documented in the member's medical record.
Definition of anesthesia time: 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.
CMS-based reimbursement formula: The reimbursement formula for anesthesia allowance is based on CMS guidelines.
Modifier requirement in primary modifier field: Modifiers identifying who performed the anesthesia service must be billed in the primary modifier field to receive appropriate reimbursement.
Denial for missing modifier: Claims submitted for anesthesiology services without the appropriate modifier will be denied.

Multiple Anesthesia Procedures

When multiple procedures occur during anesthesia:

Multiple Anesthesia Procedures: Reimbursement is based on the anesthesia procedure with the highest base unit value and the overall time of all anesthesia procedures.

Separately Reimbursable Services in Conjunction with Anesthesia

Anthem allows separate reimbursement for the following when provided with anesthesia:

Swan-Ganz catheter insertion

Reimbursable when provided with anesthesia; reimbursement based on applicable fee schedule or contracted rate with no reporting of time.

Central venous pressure (CVP) line insertion

Reimbursable when provided with anesthesia; reimbursement based on applicable fee schedule or contracted rate with no reporting of time.

Intra-arterial lines

Reimbursable when provided with anesthesia; reimbursement based on applicable fee schedule or contracted rate with no reporting of time.

Emergency intubation (must be provided in conjunction with the anesthesia procedure to be considered for reimbursement)

Reimbursable only if provided in conjunction with the anesthesia procedure.

Nonreimbursable/Excluded Anesthesia Services

Anthem Medicare Advantage does not reimburse the following anesthesia-related services:

Patient status modifiers/qualifying circumstance codes not reimbursed: Use of patient status modifiers or qualifying circumstances codes denoting additional complexity levels is not reimbursed.

Anesthesia consultations on same date as surgery: Anesthesia consultations on the same date as surgery, if part of the preoperative assessment prior to surgery, are not reimbursed.

Services for noncovered procedures: Anesthesia services performed for noncovered procedures, including services considered not medically necessary, experimental, and/or investigational, are not reimbursed.

Anesthesia by provider performing basic procedure: Anesthesia services by the provider performing the basic procedure are not reimbursed, except for a delivering physician providing continuous epidural analgesia.

Code lists & modifier billing requirements

Anesthesia Modifiers (billing required in primary modifier field)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 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.
QX	Qualified nonphysician anesthetist with medical direction by a physician. Reimbursed at 50%.
QY	Anesthesiologist medically directs one CRNA. Reimbursed at 50%.
QZ	CRNA without medical direction by a physician. Reimbursed at 100% of applicable fee schedule or contracted/negotiated amount.
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 billing anesthesia associated with the procedure in cases where anesthesia is not usually appropriate.
47	Denotes regional or general anesthesia services provided by the surgeon performing the medical procedure; not appropriate to bill Modifier 47 with anesthesia services (no additional reimbursement allowed) except obstetrical as noted.

Modifiers that identify who performed the anesthesia service (including AA, AD, QK, QX, QY, QZ, and procedure-related modifiers 23 and 47) must be billed in the primary modifier field to receive appropriate reimbursement.

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

Billing, documentation & operational actions

Billing Rule

Report anesthesia time in minutes

Report anesthesia services in minutes. Claims submitted with an indicator other than minutes may be rejected or denied.

Documentation Required

Document start/stop times and continuous attendance

Maintain start and stop times in the medical record and document that the anesthesia provider was in personal and continuous attendance.

Billing Rule

Use appropriate anesthesia modifiers

Bill anesthesia modifiers that identify who performed the service in the primary modifier field. Claims submitted without the appropriate modifier will be denied.

Documentation Required

Provide documentation for obstetrical anesthesia beyond 300 minutes

If neuraxial epidural anesthesia time exceeds 300 minutes, submit additional documentation upon dispute to support reimbursement for the excess time.

Threshold: 300 minutes

OpenPayer

Professional Anesthesia Services

Policy overview

Reimbursement & coverage requirements

Code lists & modifier billing requirements

Billing, documentation & operational actions

Key definitions

Policy revision timeline