CurrentBlue Cross Blue Shield - NevadaPolicy N/A

Professional Anesthesia Services (MA PPO)

Defines Anthem Medicare Advantage reimbursement and billing rules for professional anesthesia services including time reporting, modifiers, qualifying circumstances, included/excluded services, postoperative pain management, and related coding/billing guidelines.

Policy Summary

PayerBlue Cross Blue Shield - Nevada

PolicyProfessional Anesthesia Services (MA PPO)

Policy CodePolicy N/A

Change TypeBiennial review / clarifications

Effective DateNov 25, 2020

Next Review DateN/A

Key ActionReport anesthesia services in one-minute increments; divide minutes by 15 and round to the nearest tenth and document start/stop times in the medical record.

SourceLink

POLICY UPDATE CHANGES

Biennial Review: definition section updated and language changes

Multiple historical revisions documented (2010-2020) including modifier placement, TEE coding updates, and medication reimbursement clarifications.

MultipleCPT/Code ranges referenced

1Time reporting increment (minute)

15Minutes per time unit

100%Max combined reimbursement physician + non-physician

Policy overview & scope

Purpose: This policy defines Anthem Medicare Advantage reimbursement and billing rules for professional anesthesia services and aligns reimbursement methodology with the American Society of Anesthesiologists (ASA) anesthesia formula and National Correct Coding Initiative (NCCI) guidance. It provides payer edits and instructions covering time reporting and conversion, required modifiers and modifier placement, qualifying circumstances, included versus separately payable services, postoperative pain management, oral surgery coding interactions, and rules for multiple procedures and unusual positioning.

Scope summary: Applies to professional anesthesia services billed to Anthem Medicare Advantage and describes: calculation of time units (report minutes, divide by 15 and round to nearest tenth), requirement to report anesthesia time in one-minute increments and document start/stop times, primary modifier placement for provider-identifying modifiers, limitation that combined physician and non-physician reimbursement will not exceed 100% of the eligible amount, treatment of multiple procedures (report only the most complex base anesthesia code; add-on codes 01953, 01968, and 01969 are eligible for separate reimbursement), field avoidance minimum base unit rule (minimum base value 5 for certain positions), qualifying circumstance codes (e.g., 99100, 99116, 99135, 99140), services included in the global anesthesia reimbursement (examples: echocardiography, inhalation treatments, EEG, airway placement, noninvasive monitoring, peripheral IV placement, medications in facility settings), and conditions for separate reimbursement of specific procedures (e.g., central venous lines, Swan-Ganz, intra-arterial lines, and TEE codes 93312-93317 when distinct and properly modifier-appended).

Effective date: 2020-11-25. Last review/approval date: 2021-09-22.

Key Policy Facts

PayerBlue Cross Blue Shield - Nevada (Anthem MA)

PolicyProfessional Anesthesia Services reimbursement

Policy NumberN/A

Effective Date2020-11-25

Last Review2021-09-22

StatusCURRENT

Key ActionFollow modifier placement and time reporting rules to avoid denials

Code lists and coding categories

Qualifying circumstance CPT codes (report in addition to base anesthesia code)CPTCovered

99100	Anesthesia for patient of extreme age
99116	Anesthesia complicated by utilization of total body hypothermia
99135	Anesthesia complicated by utilization of controlled hypotension
99140	Anesthesia complicated by emergency conditions

Add-on anesthesia codes eligible for separate reimbursementCPTCovered

01953	Add-on code (eligible for separate reimbursement)
01968	Add-on code (eligible for separate reimbursement)
01969	Add-on code (eligible for separate reimbursement)

Postoperative pain management codes (eligible separate reimbursement)CPTCovered

62320-62327	Epidural/spinal injection and catheter codes (postoperative management)
64413-64425	Peripheral nerve injection codes (postoperative management)
64445-64450	Peripheral nerve injection codes (postoperative management)
01996	Daily hospital management of epidural/subarachnoid continuous drug administration (limited rules apply)

TEE and related codes (separate reimbursement conditional)CPTCovered

93312-93317	Transesophageal echocardiography codes (may be reimbursed separately if distinct and independent; must append appropriate modifier)
93318	TEE monitoring code (considered incidental; NCCI edit logic applies)
93355	TEE guidance for transcatheter intracardiac/great vessel intervention (considered incidental; NCCI edit logic applies)

Oral surgery CDT anesthesia codesmixedCovered

D9210-D9248	CDT anesthesia codes for oral surgical procedures (eligible when reported alone; not eligible when reported with CPT anesthesia codes)
00170-00176	CPT anesthesia for intraoral procedures (not eligible for reimbursement when reported with CDT procedures)

Anesthesia-related CPT examples and referencesCPT

60000 series

Spinal/nerve injection codes referenced for modifier QK/QX/QY 50% rule

Coverage rules and criteria

Time reporting and reimbursement calculation

Anesthesia time reporting and unit conversion rules required for reimbursement.

Time reporting and conversion: Providers must report anesthesia services in one-minute increments and note minutes in the units field.

Minutes to time units: Number of minutes reported is divided by 15 and rounded to the nearest tenth to derive time units for reimbursement.15 minutes per time unit

Documentation of start/stop: Start and stop times must be documented in the member's medical record; anesthesia time starts with preparation for administration and stops when provider is no longer in personal attendance.

Required billing, documentation & denial risks

Billing Rule

Report anesthesia time in minutes and convert to units

Report anesthesia services in one-minute increments in the units field. Divide reported minutes by 15 and round to the nearest tenth to derive time units. Document anesthesia start and stop times in the member's medical record. If there is an interruption in anesthesia, time may be counted in blocks only when the time counted reflects continuous anesthesia services. Claims submitted with an indicator other than minutes may be rejected or denied.

Report minutes in one‑minute increments.
Divide minutes by 15 and round to the nearest tenth to get time units.
Document start and stop times in the medical record.
Interruptions may be combined into blocks only if continuous anesthesia services are provided during the counted time.
Claims with non‑minute indicators may be rejected or denied.

Definitions

AnesthesiaAdministration of medication to allow procedures without pain; may include loss of consciousness.

Base Units (BU)Units assigned to a specific anesthesia CPT code derived from the ASA Anesthesia Relative Value Guide.

Conversion Factor (CF)A single unit rate used in the calculation for anesthesia reimbursement.

Time Units (TU)An increment of fifteen (15) minutes where each 15-minute increment constitutes one time unit.

GeneralAnesthesia affecting the entire body and accompanied by a loss of consciousness.

LocalLoss of sensation in a limited and superficial area of the body.

Regional

Document revision timeline

2020-11-25effective_date

Effective Date: 11/25/2020 retained.

2021-09-22last_reviewLatest

Last Approval Date 09/22/2021; Biennial Review: definition section updated and language changes.

2010-2020historical_revisions

Multiple historical revisions (2010-2020) documenting administrative, wording and formatting edits, modifier placement clarifications, TEE coding updates, and medication/post-op pain management coding clarifications; most changes were non‑material.

Policy Summary

PayerBlue Cross Blue Shield - Nevada

PolicyProfessional Anesthesia Services (MA PPO)

Policy CodePolicy N/A

Change TypeBiennial review / clarifications

Effective DateNov 25, 2020

Next Review DateN/A

Key ActionReport anesthesia services in one-minute increments; divide minutes by 15 and round to the nearest tenth and document start/stop times in the medical record.

SourceLink

On This Page

Interrupted anesthesia: Anesthesia time can be counted in blocks if there is an interruption, provided only continuous anesthesia service time is counted.

Claims indicator requirement: Claims submitted with an indicator other than minutes may be rejected or denied.

Modifier and provider reporting rules

Required modifier placement and provider reporting rules to determine reimbursement and edits.

Modifier usage: Anesthesia modifiers must be appended to the procedure code to indicate the specific anesthesia service or who performed the service.

Primary modifier placement: Modifiers identifying who performed the anesthesia (for example AA, AD, QK, QX, QY, QZ) must be billed in the primary modifier field to receive appropriate reimbursement.

MAC modifiers: Modifiers G8, G9, or QS may be reported in a subsequent modifier field when the service rendered is monitored anesthesia care (MAC).

Denial for missing modifier: Claims submitted for anesthesiology services without the appropriate modifier will be denied.

Combined reimbursement cap: Total reimbursement for 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.100%

Multiple procedures

Rules when multiple procedures occur during the same anesthesia episode.

Report most complex service only: When anesthesia services are provided for multiple surgical procedures, only the anesthesia procedure code for the most complex service should be reported.

Use base units for primary only: Base units are only used for the primary procedure; if two separate anesthesia codes are reported the lesser procedure will be denied.

Add-on code exceptions: Exception: add-on codes 01953, 01968, and 01969 are eligible for separate reimbursement in addition to the primary procedure code.

Separate subsequent session exception: If Anthem determines a separate subsequent operative session occurred with more than an hour separation from the initial anesthesia, the second anesthesia service may be eligible for separate reimbursement.> 1 hour separation

Field avoidance and unusual positioning

Minimum base unit and reimbursement eligibility for field avoidance or unusual positioning.

Minimum base units for field avoidance/positioning: Procedures requiring field avoidance or any position other than supine or lithotomy must have a minimum base value of 5 regardless of any lesser base value assigned.Minimum base value = 5

Modifier 22 ineligibility for field avoidance: Field avoidance is not eligible for additional reimbursement even when reported with modifier 22.

Qualifying circumstances (additional reimbursement)

CPT qualifying circumstance codes reportable in addition to the base anesthesia code; Anthem will determine mutual exclusivity.

99100: Anesthesia for patient of extreme age (younger than one year and older than 70).

99116: Anesthesia complicated by utilization of total body hypothermia.

99135: Anesthesia complicated by utilization of controlled hypotension.

99140: Anesthesia complicated by emergency conditions; eligible for separate reimbursement except in specified mutually exclusive situations (Anthem will determine mutual exclusivity with the base anesthesia code).

Mutual exclusivity determination: Anthem will determine when there is a mutually exclusive relationship between a qualifying circumstance code and the reported base anesthesia code; some uses may be denied.

Oral surgery anesthesia reporting restrictions

Restrictions and coding rules specific to oral surgery anesthesia reporting.

CDT codes for oral surgery anesthesia: Anesthesia for covered oral surgical procedures is reportable with CDT-based anesthesia codes D9210-D9248.

CDT and CPT mutually exclusive: CDT anesthesia codes D9210-D9248 will not be eligible for separate reimbursement when reported with CPT anesthesia procedure codes.

CPT intraoral codes not eligible with CDT: CPT anesthesia codes 00170-00176 for intraoral procedures will not be eligible for reimbursement when reported with CDT procedures.

Modifier 47 for oral surgeon: An oral surgeon who reports a CPT procedure and also provides an anesthesia service must append modifier 47; no additional reimbursement will be made in this instance.

Services included/excluded in global anesthesia reimbursement

Services considered included in global anesthesia reimbursement (not separately payable) and examples of included services.

Global reimbursement scope: Global reimbursement includes procedures integral to administration of anesthesia from initial pre-anesthesia evaluation through the time the anesthesiologist or other qualified provider is no longer in personal attendance.

Included services (examples)

Echocardiography
Inhalation treatments
Electroencephalogram (EEG)
Laryngoscopy and bronchoscopy procedures
Tube placement: Placement of endotracheal and naso-gastric tubes
Non-invasive monitoring: Placement/interpretation of non-invasive monitoring (ECG, temperature, blood pressure, pulse oximetry, CO2, capnography, mass spectrometry, vital capacity)
IV placement/med administration: Placement of peripheral IV lines and administration of fluids, anesthetic, or other medications through a needle or tube into a vein
Venipuncture and transfusion

E/M inclusion and nerve block note: One-day preoperative E/M and 10-day postoperative E/M related to the surgical episode are included in global reimbursement for the anesthesiologist or provider in the same anesthesia group; nerve block injections for pain management may be eligible for separate reimbursement (see postoperative pain management section).

Medication non-separability in facility: When an anesthesiologist or other professional provider separately reports a medication in a facility setting, the medication will not be eligible for separate reimbursement (facility charge covers medications including Propofol).

Services eligible for separate reimbursement

Services that may be eligible for separate reimbursement when distinct from the anesthesia service.

Examples of separately payable services: Central venous pressure line insertion; Swan-Ganz catheter insertion; intra-arterial lines.

TEE distinct service: Transesophageal echocardiography (TEE) (CPT 93312-93317) may be reimbursed separately when performed as a distinct and independent procedure; the appropriate modifier must be appended to the TEE code to be eligible for separate reimbursement.

TEE incidental/NCCI logic: If TEE is performed for monitoring purposes (e.g., CPT 93318) or guidance of transcatheter interventions (e.g., CPT 93355), Anthem follows NCCI edit logic and considers those codes incidental; a bypass modifier will not override.

Postoperative pain management (separate reimbursement rules)

Postoperative pain management services eligibility and billing rules.

Separate reimbursement eligibility: Postoperative management services by an anesthesiologist (injection or catheter into epidural space or major nerve) are eligible for separate reimbursement; time units do not apply.

Applicable code ranges: Applicable codes/ranges: 62320-62327, 64413-64425, and 64445-64450; daily management code 01996 has specific limitations.

Bilateral billing guidance: When postoperative management services are performed bilaterally, report the unilateral code once with modifier 50 and reimbursement will be 150% of the allowance for the code.150%

01996 once per date rule: CPT 01996 (daily hospital management of epidural/subarachnoid continuous drug administration) is eligible for reimbursement once per date of service following the surgery date; when 01996 is reported with an anesthetic injection code only the injection code is eligible and modifiers will not override edits.Once per date of service post-op

QK/QX/QY 50% rule: When modifier QK, QX, or QY is appended to applicable spinal/nerve injection codes (for example 60000 series postoperative/nerve block procedures), the reimbursement percentage of 50% will apply.50%

01996 and modifiers/qualifying codes denial: 01996 reported with a physical status modifier or qualifying circumstance codes will be denied.

Billing Rule

Use correct primary modifier placement

Append modifiers that identify who performed the anesthesia in the primary modifier field to receive appropriate reimbursement. Examples of primary modifiers include AA, AD, QK, QX, and QY. Modifiers such as G8, G9, or QS may be reported in a subsequent modifier field when the service rendered is monitored anesthesia care (MAC). Claims submitted without the appropriate modifier will be denied.

Primary modifiers (bill in first modifier field): AA, AD, QK, QX, QY.
MAC informational modifiers (report in subsequent modifier field): G8, G9, QS.
Claims without the appropriate modifier will be denied.

Billing Rule

Do not bill multiple anesthesia base codes for multiple procedures

When multiple surgical procedures occur during the same anesthesia episode, report only the anesthesia procedure code for the most complex service; base units apply only to the primary procedure. If two separate anesthesia base codes are reported, the lesser procedure will be denied. Exceptions: add‑on anesthesia codes 01953, 01968, and 01969 are eligible for separate reimbursement in addition to the primary procedure.

Report only the anesthesia code for the most complex procedure (base units apply only to primary).
Reporting two separate base anesthesia codes will result in denial of the lesser code.
Exceptions (eligible as add‑ons): 01953, 01968, 01969.

Documentation Required

Document anesthesia start/stop and continuous service interruptions

Document anesthesia start and stop times and any interruptions in the medical record to support reported time units. Start time begins with preparation of the member for administration of anesthesia and ends when the anesthesia provider is no longer in personal attendance. If anesthesia is interrupted, time may be counted in blocks only if the documented time reflects continuous anesthesia services; maintain clear documentation to support billing.

Document start and stop times to support time units.
Define start as preparation for administration and stop when provider no longer in personal attendance.
If interrupted, only count time in blocks when continuous anesthesia services are documented.
Maintain anesthesia record documentation to support claimed units.

Denial Risk

Medication charges in facility setting

When a professional provider separately reports a medication in a facility setting, the medication charge (including Propofol) is considered included in the facility's charge and will not be eligible for separate reimbursement; such charges may be denied.

Separately reported medications in facility settings are not eligible for separate reimbursement.
This includes Propofol and unclassified/unspecified drug codes.
Separate medication charges may be denied.

Billing Rule

TEE reporting requirements

Transesophageal echocardiography (TEE) codes 93312–93317 may be eligible for separate reimbursement only when TEE is performed as a distinct and independent procedure and the appropriate modifier is appended to the TEE code. TEE monitoring (93318) and guidance for transcatheter interventions (93355) are considered incidental per NCCI edit logic and are not payable separately; a bypass modifier will not override this logic.

TEE codes potentially reimbursable if distinct/independent: 93312–93317 (must append appropriate modifier).
TEE monitoring/guidance codes considered incidental: 93318 and 93355; NCCI logic applies.
A bypass modifier will not override NCCI edit logic for incidental TEE codes.

Billing Rule

Postoperative pain management coding

Postoperative pain management injections and catheter insertions are eligible for separate reimbursement (time units do not apply) using codes 62320–62327, 64413–64425, and 64445–64450. For bilateral services report the unilateral code once with modifier 50; the allowance will be 150% of the unilateral code. CPT 01996 (daily hospital management of epidural/subarachnoid continuous drug administration) is payable once per date of service following the surgery date; when 01996 is reported with an anesthetic injection code only the injection code is eligible for reimbursement and modifiers will not override edits. When QK, QX, or QY is appended to applicable spinal/nerve injection codes, a 50% reimbursement percentage applies.

Post‑op injection/catheter codes payable separately: 62320–62327, 64413–64425, 64445–64450.
Bilateral: report unilateral code once with modifier 50; reimbursement = 150% of allowance.
CPT 01996 payable once per date of service post‑op; if billed with an anesthetic injection code, only the injection code is payable.
QK/QX/QY appended to applicable spinal/nerve injection codes results in 50% reimbursement.

Denial Risk

Qualifying circumstance mutual exclusivity

Qualifying circumstance codes (for example, 99140) are subject to Anthem review for mutual exclusivity with the reported base anesthesia code; Anthem may determine certain uses are mutually exclusive and deny separate reimbursement. For example, 99140 is eligible for emergency reimbursement generally but will not be reimbursed when reported for specified unscheduled routine obstetric deliveries per policy.

Anthem determines mutual exclusivity between qualifying circumstance codes and base anesthesia codes.
99140 (anesthesia complicated by emergency conditions) is generally payable but may be denied for certain obstetric uses as specified by the policy.
Claims may be denied when Anthem determines the qualifying circumstance is mutually exclusive with the base code.

Loss of all forms of sensation of a particular region of the body.