CurrentBlue Cross Blue Shield - OklahomaPolicy CPCP010

Cpcp010 Anesthesia Information 03 29 23

Defines Blue Cross Blue Shield Oklahoma's coding, modifier, time/unit, base unit, qualifying circumstance, and reimbursement rules for anesthesia services billed on the CMS 1500 form; includes limitations, exclusions, and modifier guidance for anesthesiologists, CRNAs, and AAs. Applies to in-network professional providers and references ASA/RVG base units and conversion-factor methodology.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyCpcp010 Anesthesia Information 03 29 23

Policy CodePolicy CPCP010

Change Typeclarified

Effective DateMar 30, 2023

Next Review Date

Key ActionWhen multiple surgical procedures occur during one anesthesia administration, report only the single anesthesia code with the highest Base Unit Value and include combined total anesthesia time; add-on codes are exceptions (e.g., 01953, 01968, 01969).

SourceLink

POLICY UPDATE CHANGES

Committee approval and plan effective date recorded; ad-hoc review performed.

MultipleModifier categories documented

Time+Base+ModifiersPayment formula

01991/01992/01968/01969Special-code groups

Policy overview

This is Blue Cross Blue Shield of Oklahoma's anesthesia billing, coding and reimbursement guidance (Policy Number CPCP010), effective 2023-03-30 (Enterprise Clinical Payment and Coding Policy Committee approval 03/14/2023).

Scope: Applies to anesthesia services billed on the CMS 1500 form for in-network professional providers and provides rules for coding, modifiers, time/unit reporting, base units and reimbursement using the ASA/Relative Value Guide base points and a conversion-factor methodology.

High-level methodology: payment is determined using Total units = (Time Units + Base Units Value + Modifying Unit(s) Value) x Conversion Factor, with base points derived from the ASA Relative Value Guide and time measured per the policy increments.

Policy NumberCPCP010

Effective Date2023-03-30

Last Review2023-03-14

Next Review

Policy TitleCpcp010 Anesthesia Information 03 29 23

PayerBlue Cross Blue Shield - Oklahoma

Reimbursement methodology & coverage rules

General reimbursement methodology

Anesthesia procedure payment determination

Total units allowed = (Time Units + Base Units Value + Modifying Unit(s) Value) x Conversion Factor

Time units rule: Time units are measured in 15-minute increments for the first 2 hours, then 10-minute increments thereafter15-minute increments for first 2 hours; 10-minute thereafter

Anesthesia time reporting: Anesthesia time begins when provider physically starts to prepare patient for induction in the operating room (or equivalent) and ends when provider is no longer in constant attendance and patient may be safely placed under postoperative supervision

Base points are derived from the ASA Relative Value Guide in effect on date of service; newly established codes paid at determined rates until update implemented

Multiple procedures reporting: When multiple surgical procedures performed during single anesthesia administration, report a single anesthesia code for the most complex service (highest Base Unit Value) and include combined time for all procedures

Exceptions: add-on anesthesia codes per policy

Limitations / Exclusions / Duplicate service rules

When services will be denied or not separately reimbursed

Exclusions to methodology: Certain procedure codes may be excluded from the time/base methodology; refer to specific fee schedules

Duplicate submission rule: When duplicate anesthesia services are billed by same or different physician or qualified professional for same patient on same date of service, the claim will be denied; Plan reimburses only the first submission of a duplicate code

Postoperative evaluation: Routine postoperative evaluation is included in the base unit; postoperative E/M related to surgery not separately reportable by anesthesiologist except when significant, separately identifiable ongoing critical care services are provided

CPT 00104 exclusion: Reimbursement for CPT 00104 is not allowed when anesthesia is performed by a psychiatrist (or other qualified healthcare professional) in addition to ECT services (CPT 90870)

Time unit increment rule15-minute increments for first 2 hours; 10-minute increments thereafter

Modifier 22 additional payment conditionsDocumentation must be in the member's anesthesia record; base unit < 5; procedure around head/neck/shoulder and/or non-supine position

Modifier and code usage guidance

Modifiers and provider identification

Modifiers to identify performer/supervision and service characteristics

First modifier position (identify performer/supervision): AA - Anesthesia services performed personally by the anesthesiologist; AD - Medical supervision by a physician, more than four concurrent anesthesia procedures; QK - Medical direction of two, three or four concurrent anesthesia procedures involving qualified individuals; QY - Medical direction of one CRNA by an anesthesiologist; QX - CRNA service with medical direction by a physician; QZ - CRNA service without medical direction by a physician

Append appropriate first-position modifier when applicable

Second modifier position (service characteristics): QS - Monitored anesthesia care (MAC); G8 - MAC for deep complex/markedly invasive procedure; G9 - MAC for patient with severe cardiopulmonary condition; GC - Service performed in part by resident under direction of teaching physician; GE - Service performed by resident without presence of teaching physician under primary care exception; GF - Nonphysician services in a critical access hospital; 22 - Increased Procedural Services (applied for field avoidance only); 23 - Unusual Anesthesia; 47 - Anesthesia by Surgeon (Anesthesiologist not covered with this modifier)

Append appropriate second-position modifier to describe service characteristics

Physical status modifiers

ASA Physical Status modifiers add modifying units

Physical status modifiers and unit values: P1 - normal healthy person (Unit value = 0); P2 - mild systemic disease (Unit value = 0); P3 - severe systemic disease (Unit value = 1); P4 - severe systemic disease that is a constant threat to life (Unit value = 2); P5 - moribund patient not expected to survive without operation (Unit value = 3); P6 - declared brain-dead patient whose organs are being removed for donor purposes (Unit value = 0)

Modifiers add modifying units to base unit value when applicable

First modifier position (performer/supervision)Modifier

AA	Anesthesia services performed personally by the anesthesiologist
AD	Medical supervision by a physician, more than four concurrent anesthesia procedures
QK	Medical direction of two, three or four concurrent anesthesia procedures involving qualified individuals
QY	Medical direction of one certified registered nurse (CRNA) by an anesthesiologist
QX	CRNA service with medical direction by a physician
QZ	CRNA service: without medical direction by a physician

Second modifier position (service characteristics)Modifier

QS	Monitored anesthesia care service (MAC)
G8	MAC for deep complex, complicated, or markedly invasive surgical procedure
G9	MAC for patient with history of severe cardiopulmonary condition
GC	Service performed in part by a resident under direction of teaching physician
GE	Service performed by resident without presence of teaching physician under primary care exception
GF	Nonphysician services in a critical access hospital
22	Increased Procedural Services (applied for field avoidance only)
23	Unusual Anesthesia
47	Anesthesia by Surgeon (Anesthesiologist not covered with this modifier)

Qualifying circumstance add-on CPT codesCPTCovered

99100	ANESTHESIA (Unit value = 1)
99116	ANESTHESIA, LOW BODY TEMP (Unit value = 5)
99135	ANESTHESIA, LOW BLOOD PRESSURE (Unit value = 5)
99140	ANESTHESIA IN EMERGENCY (Unit value = 2)

Base point units only procedure codesCPTCovered

01991	ANESTH NERVE BLOCK/INJ (allowed for base point units only)
01992	ANESTH N BLOCK/INJ PRONE (allowed for base point units only)

Time-only procedure codesCPTCovered

01968	ANES/ANALG CS DELIVER ADD-ON (time only)
01969	ANESTH/ANALG CS HYST ADD-ON (time only)

General anesthesia CPT code range referenced for duplicate rulesCPT

00100-01999	General anesthesia service codes; highest submitted charge eligible when multiple submitted (secondary denied)
00104	Anesthesia code with reimbursement exclusion when performed by psychiatrist with ECT CPT 90870

Base-only, time-only, and qualifying circumstance codes

Qualifying Circumstances (add-on codes)

Qualifying circumstance add-on units to be used with the anesthesia service having highest Base Unit Value

Qualifying circumstance add-on codes: CPT 99100 - ANESTHESIA (Unit Value = 1); CPT 99116 - ANESTHESIA, LOW BODY TEMP (Unit Value = 5); CPT 99135 - ANESTHESIA, LOW BLOOD PRESSURE (Unit Value = 5); CPT 99140 - ANESTHESIA IN EMERGENCY (Unit Value = 2)

Qualifying circumstances billed only in conjunction with anesthesia service with highest Base Unit Value

Base-only and Time-only procedure coding rules

Certain codes billed using base point units only or time only

Base point units only: CPT 01991 - ANESTH NERVE BLOCK/INJ (paid using base point units only); CPT 01992 - ANESTH N BLOCK/INJ PRONE (paid using base point units only)base point units only

These codes are not paid based on time

Time-only procedure codes: CPT 01968 - ANES/ANALG CS DELIVER ADD-ON (time only); CPT 01969 - ANESTH/ANALG CS HYST ADD-ON (time only)time only

These codes are not based on base point units

Billing, documentation, and denial risk highlights

Billing Rule

Report single anesthesia code for multiple procedures

When multiple surgical procedures are performed during one anesthesia administration, report only the single anesthesia code with the highest Base Unit Value (general anesthesia CPT range 00100-01999) and include the combined total anesthesia time for all procedures. Exceptions: add-on anesthesia codes (for example 01953, 01968, 01969) may be reported in addition.

Denial Risk

Duplicate service denial

Duplicate anesthesia services billed for the same patient on the same date of service by the same or different providers will be denied; the Plan will reimburse only the first submission of a duplicate anesthesia code.

Billing Rule

CRNA/AA reimbursement and supervision

BCBSOK reimburses 100% of the allowable for covered anesthesia services rendered by a CRNA/AA. Report CRNA/AA services with the appropriate modifiers (QX, QY, QZ) to identify the service/supervision arrangement. Supervision or direction of CRNA/AA services is not eligible for separate reimbursement and is the provider's responsibility.

Documentation Required

Modifier 22 documentation requirements

When Modifier 22 is used to indicate substantially greater anesthesia work (e.g., field avoidance), include documentation in the member's anesthesia record supporting the additional work and the reason. Additional payment for Modifier 22 is subject to conditions: documentation must be in the anesthesia record; the base unit must be less than 5; and the procedure must be performed around the head/neck/shoulder girdle and/or require a non‑supine position.

Billing Rule

Time reporting rule

Anesthesia time begins when the provider physically starts to prepare the patient for induction of anesthesia in the operating room (or equivalent) and ends when the provider is no longer in constant attendance and the patient may be safely placed under postoperative supervision. Time units are measured in 15‑minute increments for the first 2 hours, then 10‑minute increments thereafter.

Billing Rule

Use appropriate modifiers

Append appropriate first‑ and second‑position anesthesia modifiers to identify the performer/supervision and service characteristics. First‑position examples: AA, AD, QK, QY, QX, QZ. Second‑position examples: QS, G8, G9, GC, GE, GF, 22, 23, 47. Apply modifiers in the first and second positions per the policy guidance.

OpenPayer

Cpcp010 Anesthesia Information 03 29 23

Policy overview

Reimbursement methodology & coverage rules

Modifier and code usage guidance

Base-only, time-only, and qualifying circumstance codes

Billing, documentation, and denial risk highlights

Definitions

Policy revision timeline