CurrentBlue Cross Blue Shield - South CarolinaPolicy N/A

Hiai_216525_23_Anesthesia Guidelines_01 12 23 Bcbs?Cvid=Oqxue 6&Mod=Ajperes

Policy governs BlueCross BlueShield of South Carolina and BlueChoice HealthPlan reimbursement and billing rules for anesthesia services, including recognized modifiers, qualifying circumstances, risk modifiers, monitored anesthesia care, maternity epidurals, standby anesthesia, anesthesia units (base and time), exclusions, and special catheter reimbursement rules.

Policy Summary

PayerBlue Cross Blue Shield - South Carolina

PolicyHiai_216525_23_Anesthesia Guidelines_01 12 23 Bcbs?Cvid=Oqxue 6&Mod=Ajperes

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionFile anesthesia claims using CPT anesthesia codes and the recognized modifiers (AA, AD, QK, QY, QX, QZ, QS, G8, G9, P3-P5) as applicable.

SourceLink

POLICY UPDATE CHANGES

No material changes — brief indicates no material clinical or coverage changes.

9Key billing rules / sections

3Monitored anesthesia MAC modifiers reimbursed

3Risk modifier levels (P-3,P-4,P-5)

Policy summary

BlueCross BlueShield of South Carolina and BlueChoice HealthPlan govern reimbursement and billing for anesthesia services and require filing claims using CPT anesthesia codes and recognized modifiers. The policy aligns base units with Medicare (Medicare base units), specifies that providers report anesthesia time in minutes with adjudication based on 15-minute increments rounded to the nearest tenth (example: 49 minutes = 3.3 time units), and lists qualifying circumstances, monitored anesthesia care, risk modifiers, maternity epidurals, standby anesthesia, exclusions, and catheter/line reimbursement rules. Last review: 2023-01.

Policy metadata and thresholds

PolicyAnesthesia billing and modifier reimbursement rules (BlueCross BlueShield of South Carolina / BlueChoice HealthPlan)

PayerBlue Cross Blue Shield of South Carolina / BlueChoice HealthPlan

StatusCURRENT

Last review2023-01

Effective date

Next review

Time unit calculation increment15-minute increments, rounded to nearest tenth

Coverage criteria and exclusions

General Coverage Conditions

Anesthesia services covered when ALL of the following are met:

ALL of the following

The service is billed using CPT anesthesia codes by an anesthesiologist or certified registered nurse anesthetist (CRNA).
The anesthesia is requested by the operating physician and performed by a nurse anesthetist or physician other than the operating physician for a covered surgical service.
If the operating physician performs anesthesia or sedation as part of the surgical or diagnostic procedure, the service is billed as part of that procedure and separate anesthesia benefits are not provided.
Local anesthesia is considered an integral part of the surgical procedure and is not separately reimbursed.

Anesthetic or sedation performed by operating physician

Anesthetic or sedation performed by the operating physician: covered when ALL of the following are met:

ALL of the following

The anesthetic or sedation is performed as part of the surgical or diagnostic procedure by the operating physician.
Local anesthesia performed by the operating physician is integral to the surgical procedure and is not separately reimbursed.

Monitored Anesthesia Care (MAC) Reimbursement

Monitored Anesthesia Care (MAC) reimbursement rules:

ALL of the following

BlueCross and BlueChoice may reimburse modifiers QS, G8 and G9 only if a physician personally performs the procedure (modifier AA on the claim) and the procedure meets medical necessity criteria.
BlueCross and BlueChoice will not reimburse modifiers QK, QX, QY and QZ for supervision of monitored anesthesia care (MAC).
BlueCross and BlueChoice will not reimburse CRNAs for MAC services.
Modifiers QS, G8, and G9 must appear in the second modifier field on the claim form when billed.

Anesthesia Risk Modifiers

Anesthesia Risk Modifiers (paid only when the physician personally administers the anesthesia and reports modifier AA on the primary anesthesia code):

ALL of the following

Risk modifiers must be placed in the second modifier field of the claim form.
Risk modifiers are payable only when the physician (modifier AA) administers the anesthesia personally; no separate payment for risk modifiers reported by CRNAs or by anesthesiologist supervision of CRNAs.
Risk modifier details
- P3 — Add one time unit when the patient has a severe systemic disease (e.g., uncontrolled diabetes or hypertension requiring medication).
- P4 — Add two time units when the patient has a severe systemic disease that is a constant threat to life (e.g., severe respiratory or cardiac disease).

Excluded / Not Separately Reimbursed Services

Excluded / Not Separately Reimbursed Services: BlueCross will not reimburse the following services separately (these are included in the allowance for other services or are noncovered):

ANY of the following

Administration of anesthesia for noncovered services (for example, cosmetic surgery).
Preoperative anesthesia consultation when provided in conjunction with other surgical or medical services.
Transesophageal cardiography when provided in conjunction with other surgical or medical services.
Emergency intubation when provided in conjunction with other surgical or medical services.
Administration of anesthesia by the attending surgeon or surgical assistant (except as specifically outlined elsewhere in the policy).

Nerve Blocks; Catheter and Line Billing with Anesthesia

Nerve Blocks and Catheter/Line Billing with Anesthesia:

ALL of the following

Administration of a nerve block is included in the allowance for total anesthesia time and is not eligible for separate reimbursement when provided as part of anesthesia for a surgical procedure.
When a nerve block is a separate procedure performed for treatment of a nonsurgical condition or for nonpostoperative pain management, bill the appropriate surgical or procedural code for that service (it is not billed as part of the anesthesia time).
Providers should report catheters and invasive lines (for example Swan-Ganz catheter, central venous pressure (CVP) lines, and arterial lines) using the appropriate procedure codes; follow special processing procedures for catheters per payer guidance and do not assume separate anesthesia benefit unless specifically covered.

Recognized codes and modifiers

Recognized Anesthesia Modifiers (Anesthesiologist)Modifier

AA	Anesthesia services performed personally by an anesthesiologist (includes reimbursement of an employed CRNA)
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

Recognized CRNA ModifiersModifier

QX	CRNA service with medical direction by a physician
QZ	CRNA service without medical direction by a physician

Monitored Anesthesia Care ModifiersModifier

QS	MAC service (must appear in the second modifier field)
G8	MAC for a deep complex, complicated or markedly invasive surgical procedure (must appear in the second modifier field)
G9	MAC for a patient with history of severe cardiopulmonary condition (must appear in the second modifier field)
QK	Not reimbursed for supervision of MAC
QX	Not reimbursed for supervision of MAC
QY	Not reimbursed for supervision of MAC
QZ	Not reimbursed for supervision of MAC

Risk ModifiersModifier

P3	P-3: Add one time unit when a patient has a severe systemic disease (example: uncontrolled diabetes or hypertension requiring medication)
P4	P-4: Add two time units when a patient has a severe systemic disease that is a constant threat to life (example: severe respiratory or cardiac disease)
P5	P-5: Add three time units when the patient is not expected to survive for 24 hours with or without the operation (example: multiple severe trauma or severe head injury)

Epidural Anesthesia CPT Codes (maternity)CPT

01967	Obstetrical epidural administration — normal delivery
01968	Obstetrical epidural administration — cesarean section (used in conjunction with 01967)

Modifiers QS, G8, and G9 are reimbursed for Monitored Anesthesia Care only when the physician personally performs the procedure (modifier AA) and these modifiers must appear in the second modifier field. Modifiers QK, QX, QY, and QZ will not be reimbursed for supervision of MAC, and CRNAs are not reimbursed for MAC. Providers must file claims using CPT anesthesia codes and the appropriate modifiers as applicable.

Billing, documentation and submission rules

Billing Rule

File anesthesia claims with CPT anesthesia codes and appropriate modifiers

File anesthesia claims using CPT anesthesia procedure codes and the recognized anesthesia modifiers. Include the appropriate modifier(s) on the claim to reflect the provider role or circumstance.

Billing Rule

Report anesthesia time in minutes; BlueCross converts to 15-minute time units

Report actual anesthesia time in minutes on claims. BlueCross adjudicates time by converting minutes to 15-minute units and rounds to the nearest tenth.

Time unit calculation example: 49 minutes ÷ 15 = 3.266 → rounded to 3.3 time units

Documentation Required

Risk modifier documentation and physician administration requirement

Risk (P‑3, P‑4, P‑5) modifiers are payable only when the physician personally administers the anesthesia (modifier AA) and documents the severe risk condition in the record.

P3
P4
P5
AA
Requirement: Physician (AA) must personally administer anesthesia and document the severe/systemic risk to bill P‑3/P‑4/P‑5.

Billing Rule

MAC modifier placement and physician requirement

For Monitored Anesthesia Care (MAC), only QS, G8, and G9 may be reimbursed and they must appear in the second modifier field. Reimbursement for MAC modifiers requires the physician to personally perform the procedure (AA) and medical necessity to be met. Modifiers QK, QX, QY, and QZ will not be reimbursed for supervision of MAC; CRNAs are not reimbursed for MAC.

QS, G8, G9 must be placed in the second modifier field
Reimbursed only when primary anesthesia code has AA and medical necessity is documented
QK, QX, QY, QZ are not reimbursed for supervision of MAC; CRNAs not reimbursed for MAC

Billing Rule

Maternity epidural billing guidance

Maternity epidural anesthesia is reimbursed as a global allowance. Use CPT 01967 for normal delivery and report both 01967 and 01968 for cesarean sections. The practitioner who inserts the epidural needle generally files the total service with modifier AA. If both physician and CRNA bill, physician should bill QK or QY and the CRNA should bill QX.

01967
01968
AA
QK
QY
QX

Billing Rule

Standby anesthesia billing

Standby anesthesia may be reimbursed when the anesthesiologist provides the personal patient care normally given when administering anesthesia (examines patient, connects monitoring lines, personally monitors) even if anesthesia is not actually administered. File claims using the appropriate anesthesia code, modifier, and time units.

Provide personal patient care equivalent to administering anesthesia
File with appropriate anesthesia code, modifier, and reported time units

Billing Rule

Nerve block billing when separate from anesthesia

When a nerve block is performed as part of anesthesia, its administration is included in the total anesthesia allowance and not eligible for separate reimbursement. If the nerve block is a distinct, separate procedure (e.g., for nonsurgical conditions or nonpostoperative pain management), bill the appropriate surgical procedure code instead.

Included in anesthesia allowance when done as part of anesthesia
Bill appropriate surgical procedure code when performed as a separate procedure for non-surgical or nonpostoperative pain management

Billing Rule

Catheter/line reimbursement split when billed with anesthesia

When catheter/line services are billed with anesthesia, payment is split: catheterization/arterial lines reimbursed at 50% of allowance and administration of anesthesia reimbursed at 100%. If billed without anesthesia: Swan‑Ganz catheter = 100% of allowance; CVP and arterial lines = 50% of allowance.

With anesthesia: catheterization/arterial lines = 50% allowance; anesthesia = 100% allowance
Without anesthesia: Swan‑Ganz = 100% allowance; CVP and arterial lines = 50% allowance

Time unit calculation and examples

Time unit calculation threshold

Time unit calculation increment15-minute increments, rounded to nearest tenth (example: 49 minutes = 3.3 time units)

Maternity epidural reimbursement rules

Billing Rule

Maternity epidural billing specifics (01967, 01968, AA, QK/QY, QX)

Key maternity epidural billing codes and modifiers: use 01967 (normal delivery) and 01968 (with cesarean), and bill with AA generally; if both physician and CRNA bill, physician should bill QK or QY and CRNA bill QX.

01967
01968
AA
QK
QY
QX

Monitored Anesthesia Care (MAC)

Billing Rule

MAC modifier placement and CRNA reimbursement limitation

For MAC, QS/G8/G9 must be in the second modifier field and are reimbursed only when the physician personally performs the procedure (AA) and medical necessity is met. CRNA supervision modifiers QK/QX/QY/QZ are not reimbursed for MAC.

QS/G8/G9 in second modifier field
Reimbursed only with AA and medical necessity
QK/QX/QY/QZ not reimbursed for MAC

Standby anesthesia rules

Billing Rule

Standby anesthesia claim filing expectations

Standby anesthesia claims should be filed with the appropriate anesthesia code, modifier, and reported time units when the anesthesiologist provides the personal patient care normally associated with administering anesthesia, even if anesthesia is not given.

File with appropriate anesthesia code, anesthesia modifier, and time units

Catheter and line billing with anesthesia

Billing Rule

Catheter/line reimbursement percentages (Swan‑Ganz, CVP, arterial)

Summary of catheter/line reimbursement when billed with or without anesthesia: with anesthesia, catheterization/arterial lines reimbursed at 50% of allowance and anesthesia at 100%; without anesthesia, Swan‑Ganz = 100% allowance and CVP/arterial lines = 50% allowance.

With anesthesia: catheter/arterial lines = 50%; anesthesia = 100%
Without anesthesia: Swan‑Ganz = 100%; CVP and arterial lines = 50%

Key definitions

Definitions

MACMonitored Anesthesia Care

Frequently asked questions

Document revisions

2023-01Last reviewLatest

Policy reviewed

Policy Summary

PayerBlue Cross Blue Shield - South Carolina

PolicyHiai_216525_23_Anesthesia Guidelines_01 12 23 Bcbs?Cvid=Oqxue 6&Mod=Ajperes

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionFile anesthesia claims using CPT anesthesia codes and the recognized modifiers (AA, AD, QK, QY, QX, QZ, QS, G8, G9, P3-P5) as applicable.

SourceLink

On This Page

P5 — Add three time units when the patient is not expected to survive for 24 hours with or without the operation (e.g., multiple severe trauma or severe head injury).

Local anesthesia (considered integral to the surgical procedure).

CRNA-provided MAC (monitored anesthesia care) — not separately reimbursed by BlueCross/BlueChoice.

Nerve block administration when included in the allowance for total anesthesia time (see Nerve Blocks criteria).