Anesthesia Services, Professional And Facility — Commercial Reimbursement Policy
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Reimbursement rules and guidelines for anesthesia professional and facility services as applied to commercial, ASO, and Blue Card Host members receiving care in North Carolina; describes payment conditions, coding, and provider responsibilities.
Added language around anesthesia modifier incompatibility denials.
Added language to update physical status modifiers, disallowing additional reimbursement.
Clarifying updates made to Reimbursement Guidelines including Modifier AD reimbursement rates and post-surgical pain blocks; removed 'Monitored Anesthesia' from Reimbursement Guidelines.
Clarification to the definition of same group practice.
Anesthesia Supplies added to Reimbursement Guidelines.
Coverage and Applicability
General reimbursement stance
Covered when ALL of the following apply:
ALL of the following
- Reimbursement requirements apply to all commercial, Administrative Services Only (ASO), and Blue Card Inter-Plan Program Host members receiving care in the North Carolina service area.
- Member benefits may vary by benefit design; the member's Benefit Booklet and contract should be reviewed before applying this policy.
- Final payment is subject to claims adjudication edits and applicable fee schedules within the provider’s scope of practice.
- Policies apply to both participating and non-participating providers and facilities.
Required Code Systems
| CPT | Use appropriate CPT codes for services rendered |
| HCPCS | Use appropriate HCPCS codes for supplies and services |
| Revenue | Use appropriate revenue codes where applicable |
Billing, Documentation, and Denials
Bill with appropriate CPT/HCPCS/revenue codes and support with documentation
Providers must bill services using appropriate CPT®, HCPCS, and/or revenue codes supported by documentation in the medical record, which includes any AI-generated content, recordings, or transcripts when applicable.
- Maintain medical records and documentation consistent with scope of practice, regulatory, and licensure requirements.
- Include AI-generated content, recordings, or transcripts in the medical record when used to support billed services.
Risk of claim review, denial, or recovery for incorrect coding
Failure to follow correct coding or reimbursement guidelines may result in claim review, denial, or recovery of payment.
- Providers are responsible for accurate medical coding and maintaining medical records.
- Policies apply to both participating and non‑participating providers and facilities; noncompliance can trigger postpayment review or recoupment.
Key Definitions
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