CurrentBlue Cross Blue Shield - OklahomaPolicy CPCP010

Cpcp010 Anesthesia Information 08 14 24

Defines coding, modifier use, time/unit and base unit calculation, qualifying circumstance add-ons, included and excluded services, duplicate/multiple claim handling, and reimbursement methodology for anesthesia services for BCBSOK in-network and out-of-network providers.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyCpcp010 Anesthesia Information 08 14 24

Policy CodePolicy CPCP010

Change Typeclarified

Effective DateAug 14, 2024

Next Review Date

Key ActionWhen multiple surgical procedures occur during a single anesthesia administration, report only the single anesthesia code with the highest Base Unit Value and report combined time for all procedures.

SourceLink

POLICY UPDATE CHANGES

Enterprise Clinical Payment and Coding Policy Committee Approval Date recorded as February 22, 2024 with Plan Effective Date August 14, 2024.

4Qualifying Circumstance Codes Listed

2Base-point-only Procedure Codes

1Time-only Procedure Codes

1Not Reimbursable CPT in Situations

This policy (Policy Number: CPCP010) is maintained by BlueCross BlueShield of Oklahoma (BCBSOK) and is effective 2024-08-14. It serves as a general reference guide governing anesthesia billing and reimbursement methodology, including coding, modifier use, time/unit and base unit calculation, qualifying circumstance add-ons, included and excluded services, duplicate/multiple claim handling, and conversion-factor based payment for anesthesia services.

Providers are responsible for ensuring billed codes accurately convey the services rendered and must follow industry coding guidelines. BCBSOK may interpret and apply this policy with reasonable discretion; however, when conflicts arise, the applicable plan document or provider contract will govern and take precedence over this policy.

Policy Dates and Identifiers

Effective Date2024-08-14

Last Review2024-02-22

Next Review

Policy NumberCPCP010

SubjectAnesthesia billing and reimbursement rules

Scope SummaryDefines coding, modifier use, time/unit and base unit calculation, qualifying circumstance add-ons, included and excluded services, duplicate/multiple claim handling, and reimbursement methodology for anesthesia services for BCBSOK in-network and out-of-network providers.

Reimbursement methodology & limitations

General Reimbursement Methodology

This section describes the general methodology BCBSOK uses to reimburse anesthesia services, including how total units are calculated, the time/points methodology, and how in-network and out-of-network allowances are handled.

Total units allowed = (Time Units + Base Units Value) x Conversion Factor.

Anesthesia procedure codes may be eligible for payment based on a time and points methodology. Not all anesthesia codes are paid using time and points; claims are subject to code edit software and provider contract terms and conditions.

When multiple surgical procedures are performed during the same anesthetic, bill the anesthesia procedure code for the most complex service. The reported anesthesia time is the combined total for all procedures.

In-network professional providers: reimbursement is based on total units formula above, using the applicable anesthesia conversion factor.

Out-of-network providers: the Plan follows industry standard guidelines and the member's benefit coverage for allowance determination.

Time Units Definition

Defines how anesthesia time is measured and reported for reimbursement.

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 safely be placed under postoperative supervision.

When anesthesia is provided for multiple procedures during the same continuous anesthetic, report the combined total anesthesia time across all procedures.

Time unit increments: 15-minute increments for the first 2 hours, then 10-minute increments thereafter. Time units are calculated per industry-standard anesthesia time reporting rules.

Base Points and Qualifying Circumstances

Base units are determined from the ASA Relative Value Guide and qualifying circumstance add-ons apply under specific rules.

Base points are determined using the American Society of Anesthesiologists Relative Value Guide in effect on the date(s) services are rendered.

Qualifying circumstance add-on units (see qualifying circumstance codes and unit values) are allowed only when billed in conjunction with the anesthesia service that has the highest base unit value for the anesthetic.

When qualifying circumstance add-ons apply, the allowed payment is calculated using the allowed conversion factor applied to the total units (time units + base units + qualifying circumstance units).

Allowed conversion factor: the conversion factor used to calculate the allowable amount is the anesthesia conversion factor applicable to the claim per contract and policy rules.

Qualifying circumstance codes and unit values:

Limitations

Limitations, exclusions, and billing rules that may lead to denial or reduction of anesthesia payment.

Certain procedure codes and services are excluded from separate anesthesia reimbursement because they are included in the base unit value (for example: preoperative and postoperative visits; administration of fluids and/or blood products incident to anesthesia care; laryngoscopy/bronchoscopy; retrobulbar injection; cardiopulmonary resuscitation, cardioversion, temporary pacemaker, or inhalation treatments).

Duplicate or unbundled billing for anesthesia services will be denied when submitted in conflict with coding guidelines or when services are already included in another payable procedure.

Postoperative Evaluation and Management (E/M) services included in the base anesthesia package are not separately reimbursable when they are part of the usual pre- and post-operative anesthesia care.

Specific non-reimbursable example: CPT 00104 billed with CPT 90870 (electroconvulsive therapy anesthesia combined with psychotherapy service) — CPT 00104 is not separately reimbursable with CPT 90870 in this context and such combinations may be denied.

Services included in base unit (not separately reimbursable)

Included and Not Separately Reimbursable Services

Services and supplies that are considered integral to anesthesia and therefore not separately reimbursable.

Included or not separately reimbursable

Pre/post-op visits: Preoperative and postoperative visits
Fluids and blood: Administration of fluids and/or blood products incident to anesthesia care (including venipuncture and/or introduction of needle or catheter)
Laryngoscopy/bronchoscopy: Laryngoscopy and/or bronchoscopy
Retrobulbar injection
CPR/cardioversion/etc: Cardiopulmonary resuscitation, cardioversion, temporary pacemaker, or inhalation treatments
Tumescent anesthesia is included in endovenous ablations and is not separately reimbursable

Multiple and duplicate anesthesia service rules

Billing Rule

Report single anesthesia code for multiple procedures

When multiple surgical procedures are performed during a single anesthesia administration, report only the single anesthesia code with the highest Base Unit Value and include combined anesthesia time for all procedures. Do not submit multiple general anesthesia service codes (00100-01999) for the same anesthesia administration; the highest submitted charge will be eligible and secondary anesthesia services will be denied (exceptions: add-on anesthesia codes such as 01953, 01968, 01969).

Affected codes: 00100-01999

Denial Risk

Duplicate claim denial

If duplicate anesthesia codes are reported by the same or different clinician for the same patient on the same date of service, the Plan will reimburse only the first submission of that code; duplicate claims may be denied.

Modifier use and documentation requirements

Modifier Use

Modifiers used to identify performer, supervision level, monitored care, teaching status, other circumstances, and physical status classification (physical status modifiers are informational only).

Modifier guidance

First-position modifiers: AA, AD, QK, QY, QX, QZ — identify whether personally performed, supervised, or directed
Second-position and other modifiers: QS, G8, G9, GC, GE, GF, 22, 23, 47 — monitoring, teaching, special circumstances
Physical status modifiers P1–P6 are recognized for classification but are not used to determine payment

Billing Rule

Modifier reporting requirements

Append the appropriate anesthesia modifiers to identify performer, supervision/medical direction, monitored care, teaching status, and special circumstances. Use first-position modifiers (AA, AD, QK, QY, QX, QZ) as applicable and second-position modifiers (QS, G8, G9, GC, GE, GF, 22, 23, 47) where indicated.

Documentation Required

Support Modifier 22 / field avoidance claims

For Modifier 22 / field-avoidance claims, include documentation in the member's anesthesia record that supports the substantially greater work and the specific reason. Additional payment consideration requires documentation in the anesthesia record and that the base unit is less than 5 units, and the procedure is performed around the head, neck, or shoulder girdle and/or the position requires a position other than supine.

Include anesthesia record documentation supporting substantial additional work
Base unit must be < 5 units for additional payment consideration
Procedure performed around head, neck, or shoulder girdle and/or non-supine position

Qualifying circumstance add-on codes

Qualifying Circumstance Add-on CPT codesCPTCovered

99100	ANESTHESIA - qualifying circumstance (unit 1)
99116	ANES/ANALG CS DELIVER LOW BODY TEMP (unit 5)
99135	ANESTHESIA LOW BLOOD PRESSURE (unit 5)
99140	ANESTHESIA IN EMERGENCY (unit 2)

Billing Rule

Qualifying Circumstance add-ons must accompany highest base unit service

Qualifying circumstance add-on codes must be billed only in conjunction with the anesthesia service that has the highest Base Unit Value.

99100
99116
99135
99140

Qualifying Circumstance Thresholds

Qualifying circumstance unit values99100=1; 99116=5; 99135=5; 99140=2

Conversion noteAllowed conversion: Qualifying Circumstances = Qualifying Circumstance Value x Conversion Factor

Time unit increments (context)Time units are 15-minute increments for first 2 hours, then 10-minute increments thereafter (used when computing total units).

Code lists and modifiers

Procedure codes allowed for base point units (not time-based)CPTCovered

01991	ANESTH NERVE BLOCK/INJ
01992	ANESTH N BLOCK/INJ PRONE

Procedure codes allowed for time only (not base point units)CPTCovered

01968

ANES/ANALG CS DELIVER ADD-ON (time only)

General anesthesia CPT range referenced for duplicate/multiple ruleCPTCovered

00100-01999

General anesthesia service codes; when multiples billed the highest submitted charge will be eligible and secondary anesthesia services will be denied (exceptions apply)

Exception add-on anesthesia codes (examples)CPTCovered

01953	Add-on anesthesia code (example exception to single-code rule)
01969	Add-on anesthesia code (example exception to single-code rule)

Physical status modifiers (informational)Modifier

P1	ASA I - normal healthy person
P2	ASA II - mild systemic disease
P3	ASA III - severe systemic disease
P4	ASA IV - severe systemic disease constant threat to life
P5	ASA V - moribund patient not expected to survive without operation
P6	ASA VI - declared brain-dead patient organ donor

First position anesthesia modifiersModifierCovered

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
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

Second position modifiers and othersModifierCovered

QS	Monitored anesthesia care service
G8	Monitored anesthesia care for deep complex procedure
G9	Monitored anesthesia care for severe cardiopulmonary condition
GC	Performed in part by resident under teaching physician direction
GE	Performed by resident without teaching physician under primary care exception
GF	Nonphysician services in a critical access hospital
22	Increased procedural services (field avoidance only; documentation required)
23	Unusual Anesthesia
47	Anesthesia by Surgeon (Anesthesiologist not covered with this modifier)

Specific CPT codes not reimbursed in specified situationsCPTNot Covered

00104

Anesthesia by psychiatrist in addition to ECT (CPT 90870) — reimbursement not allowed

Actionable billing & documentation requirements

Billing Rule

Time reporting

Report anesthesia time from when the provider begins physical preparation for induction of anesthesia to the end of constant attendance. Combine time across all procedures performed during the same anesthesia administration and report total time per the policy's time increment rules.

Report time from preparation for induction to end of constant attendance
Combine time across procedures performed during the same anesthesia administration
Time increments: 15-minute increments for first 2 hours, then 10-minute increments thereafter

Denial Risk

Included services not separately reimbursable

Certain services are included in the anesthesia base unit and are not separately reimbursable; billing these separately may result in denial.

Preoperative and postoperative visits
Administration of fluids and/or blood products (including venipuncture)
Laryngoscopy and/or bronchoscopy
Retrobulbar injection
Cardiopulmonary resuscitation, cardioversion, temporary pacemaker, or inhalation treatments
Tumescent anesthesia in endovenous ablations

OpenPayer

Cpcp010 Anesthesia Information 08 14 24

Policy overview & scope

Reimbursement methodology & limitations

Services included in base unit (not separately reimbursable)

Multiple and duplicate anesthesia service rules

Modifier use and documentation requirements

Qualifying circumstance add-on codes

Code lists and modifiers

Actionable billing & documentation requirements

Key terms

Operational thresholds

Policy changes & history