CurrentBlue Cross Blue Shield - OklahomaPolicy CPCP010

Cpcp010 Anesthesia V1 10 01 22

BCBSOK clinical payment and coding policy governing reporting, billing modifiers, unit calculation (time, base points, physical status, qualifying circumstances), allowed code categorizations (time-only, base-point-only), exclusions/limitations, and modifier usage for anesthesia services for in-network and out-of-network providers.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyCpcp010 Anesthesia V1 10 01 22

Policy CodePolicy CPCP010

Change TypeAnnual Review / Revisions

Effective DateOct 1, 2022

Next Review Date

Key ActionProviders must bill using CPT anesthesia codes (or surgical CPT plus modifier when appropriate) and append required first-position provider-role modifiers and second-position service/context modifiers as applicable.

SourceLink

POLICY UPDATE CHANGES

09/02/2022 Annual Review.

09/13/2021 Annual Review.

04/03/2020 Annual Review, Disclaimer Update.

03/08/2019 CPT Code descriptor update.

10/11/2017 New policy.

8Modifier and CPT groups listed

2Base-point-only procedure codes

2Time-only procedure codes

4Qualifying circumstance CPT codes

Policy overview

This Enterprise Clinical Payment and Coding Policy (CPCP010) serves as a general reference for anesthesia services billing and reimbursement consistent with AMA, ASA and CMS guidelines and is effective 10/01/2022 (Committee approval 09/02/2022).

The policy applies to in-network and out-of-network physicians and other qualified healthcare professionals (including anesthesiologists and CRNA/AA) and describes provider-role modifier requirements, unit calculation methodology, qualifying circumstances, allowed code categorizations, and limitations/exclusions for anesthesia services.

Key topics covered: unit calculation methodology (time units, base points, physical status modifier units, qualifying circumstance units, and conversion factor); modifier usage including required first-position provider-role modifiers (AA, AD, QK, QY, QX, QZ) and second-position service/context modifiers (QS, G8, G9, GC, GE, GF, 23, 47); allowed categorizations for base-point-only and time-only procedure codes; and limitations such as duplicate service denial, inclusion of routine postoperative evaluation and supplies in the anesthesia service, and specific code exclusions (e.g., CPT 00104 with ECT).

High-level calculation summary: for in-network professional providers Total units = Time Units + Base Units + Physical Status and Qualifying Circumstance Unit Values, and Allowed amount = Total units × Conversion Factor. Time units are counted in 15-minute increments for the first 2 hours, then 10-minute increments thereafter, and anesthesia time begins when the provider starts preparation for induction and ends when no longer in constant attendance.

Billing & reimbursement rules (payment determination and limits)

General Billing and Payment Determination

Payment for anesthesia services is determined using time units, base units (points), physical status modifiers, qualifying circumstance units, and conversion factor; rules and exclusions below apply.

Coding and single-code guidance: Report anesthesia services using CPT anesthesia five-digit procedure codes, or CPT surgical codes plus an appropriate modifier when indicated. When a single code exists that describes services rendered, report the single code and do not submit multiple codes.
Source: CPT/anesthesia coding guidance.
Provider billing roles: Anesthesiologist and CRNA/AA bill appropriate component and use appropriate anesthesia modifiers as applicable under state and federal law. BCBSOK reimburses 100% of allowable for covered anesthesia services rendered by a CRNA/AA; supervision/direction of CRNA/AA services are not separately reimbursable.
Provider responsibility and reimbursement handling.
Total units and allowed amount calculation: For in-network professional providers, total units = Time Units + Base Units + Unit Value(s) from physical status modifiers and qualifying circumstances; Allowed amount = total units x conversion factor.
Time-and-points methodology applies when eligible.

Limitations and Exclusions

Situations in which separate reimbursement or payment will be denied or limited:

Excluded procedure codes and fee schedule reference: Certain procedure codes may be excluded from the time-and-points methodology; refer to specific fee schedules.
Some codes are not paid under time-and-points per fee schedules.
Duplicate services denial: Duplicate anesthesia services billed by the same or different physician or other qualified health care professional for the same patient on the same date of service will be denied.
Exact duplicate service denial.
Routine postoperative evaluation included: Routine postoperative evaluation is included in the base unit for the anesthesia service and postoperative E/M related to the surgery are not separately reportable by the anesthesiologist except when significant, separately identifiable ongoing critical care services are provided.
Postoperative E/M not separately reportable except for significant ongoing critical care.

Modifier usage and positions

Modifier Billing Positions and Use

Modifiers identifying provider role and service context must be appended in specified positions when applicable.

First modifier position: provider-role modifiers: First modifier position: provider-role anesthesia modifiers (AA, AD, QK, QY, QX, QZ) as applicable to who performed or directed the service; append when the described conditions apply.
Required when applicable; identifies who performed or directed the service.
Second modifier position: service/context modifiers (QS, G8, G9, GC, GE, GF, 23, 47) as applicable.
List of second-position modifiers.
Physical status modifiers and unit values: Physical status modifiers (P1-P6) add unit values as specified (P3 = 1, P4 = 2, P5 = 3; P1, P2, P6 = 0).
ASA physical status modifier unit values.

Code lists (allowed, time-only, base-point-only, qualifying circumstances, exclusions)

Qualifying circumstance add-on CPT codesCPTCovered

99100	ANESTHESIA (Qualifying circumstance), 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.

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.
01969	ANESTH/ANALG CS HYST ADD-ON.

Excluded / denial example codesCPTNot Covered

00104

Anesthesia combined with ECT (90870) when performed by a psychiatrist — reimbursement not allowed in that scenario.

Actionable billing, documentation, and denial risks

Billing Rule

Submit appropriate anesthesia CPT and modifiers

Submit the appropriate anesthesia CPT procedure code(s) and required anesthesia modifiers in the first modifier position to accurately reflect who provided the service (e.g., AA, QK, QY, QX, QZ). Use second-position modifiers where applicable (e.g., QS, G8, G9, GC, GE, GF, 23, 47). Claims must use HIPAA-compliant code sets and valid code combinations.

Append AA when anesthesia services are personally performed by the anesthesiologist.
Append QK, QY when medically directing multiple concurrent procedures as defined by CPT.
Append QX when CRNA service is performed with medical direction by a physician; append QZ for CRNA service without medical direction.

Billing Rule

Calculate and report anesthesia time and units correctly

Calculate and report anesthesia time and time-based units per policy: time units are 15-minute increments for the first 2 hours and 10-minute increments thereafter. Report the combined total anesthesia time for all procedures and convert to time units accordingly.

Key definitions

Policy revision history

10/11/2017added

New policy (added)

03/08/2019revised

CPT Code descriptor update

04/03/2020revised

Annual Review, Disclaimer Update

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyCpcp010 Anesthesia V1 10 01 22

Policy CodePolicy CPCP010

Change TypeAnnual Review / Revisions

Effective DateOct 1, 2022

Next Review Date

SourceLink

On This Page

Time units calculation:

Time units: 15-minute increments for first 2 hours, then 10-minute increments thereafter.

15-minute increments for first 2 hours; 10-minute increments thereafter

Time unit increment threshold.

Time interval for anesthesia time: 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.

Defines start and end of anesthesia time.

Base points determined by ASA Relative Value Guide in effect on date of service (with transitional handling for newly established codes).

Base units source is ASA RVG.

Qualifying circumstances billing: Qualifying circumstance add-on codes (e.g., 99100, 99116, 99135, 99140) are billed only in conjunction with the anesthesia service having the highest base unit value; qualifying circumstance units are added to total units.

List and unit values provided in policy.

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

Specific reimbursement exception.

Routine supplies and equipment not reimbursable: Routine supplies, reusable and disposable equipment integral to anesthesia delivery are not separately reimbursable.

Supplies and equipment are integral to anesthesia service and not separately reimbursable.

Base-point-only procedure codes (examples): Procedure codes allowed for base point units (not time-based): 01991, 01992.

Codes listed as base-point-only.

Time-only procedure codes (examples): Procedure codes allowed for time only (not base point units): 01968, 01969.

Codes listed as time-only.

First-position anesthesia modifiers (required when applicable)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-position modifiers / service contextModifier

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

Physical status modifiersModifier

P1	Normal healthy person (ASA I), unit value = 0.
P2	Mild systemic disease (ASA II), unit value = 0.
P3	Severe systemic disease (ASA III), unit value = 1.
P4	Severe systemic disease constant threat to life (ASA IV), unit value = 2.
P5	Moribund patient not expected to survive without operation (ASA V), unit value = 3.
P6	Declared brain-dead donor (ASA VI), unit value = 0.

Time-unit increment threshold: 15 minutes for initial 2 hours, then 10-minute increments thereafter (15/10).
Anesthesia time begins when the provider physically starts preparing the patient for induction in the OR (or equivalent) and ends when the provider is no longer in constant attendance and the patient may be placed under postoperative supervision.
Total units = Time units + Base units + Physical status/qualifying circumstance units; Allowed = Total units x conversion factor.

Denial Risk

Duplicate service denial

Duplicate anesthesia services billed for the same patient, same date of service, and same or overlapping time that represent the same anesthesia component are subject to denial as duplicate services.

Do not bill multiple anesthesia procedure codes for a single continuous anesthesia service when a single CPT anesthesia code accurately describes the service.
When multiple surgical procedures occur, bill the anesthesia code that represents the most complex service; report combined total anesthesia time rather than separate overlapping time entries.
If both an anesthesiologist and CRNA/AA bill for the same service component without appropriate modifiers and supporting documentation of distinct services or allowed medical direction/supervision relationships, claims may be denied as duplicates.

Documentation Required

Support claims upon request

Support claims with documentation upon request. Retain operative/anesthesia records that substantiate reported time, services, medical direction/supervision, and any separate services billed.

Be prepared to submit anesthesia records, pre- and post-operative notes, and documentation of supervision or medical direction when requested.
Documentation should clearly show start and end times, procedures performed, providers present, and any qualifying circumstances or physical status modifiers applied.

Billing Rule

Do not separately bill routine postoperative evaluation or integral supplies

Do not separately bill routine postoperative evaluation or supplies that are integral to anesthesia services. Include usual pre- and post-operative visits, physiologic monitoring, administration of fluids/blood, and other supportive services in the anesthesia code unless CPT or this policy allows separate reporting (e.g., intra-arterial, central venous, Swan-Ganz catheter insertion).

Routine postoperative evaluation and integral supplies/monitoring services are considered included in anesthesia procedure codes and are not separately reimbursable.
Report separately only those services specifically permitted by CPT or this policy (for example, distinct invasive catheter insertions when allowed).

Billing Rule

CRNA/AA reimbursement and supervision direction

BCBSOK reimburses 100% of the allowable for covered anesthesia services rendered by a CRNA/AA. Supervision or direction of CRNA/AA services is not eligible for separate reimbursement and will be processed as provider responsibility.

When an anesthesiologist medically directs a CRNA/AA, both may bill appropriate components with proper modifiers; however, BCBSOK will not separately reimburse supervision/direction fees.
CRNA/AA services billed with appropriate CRNA/AA modifiers (e.g., QX, QZ) will be reimbursed at 100% of the allowable for covered services.

09/02/2022revisedLatest

Annual Review (Enterprise Clinical Payment and Coding Policy Committee Approval Date September 2, 2022 and Plan Effective Date October 1, 2022)