CurrentBlue Cross Blue Shield - TexasPolicy CPCP010

Cpcp010 Anesthesia 08142024

Defines billing, coding, modifier use, time/unit calculations, base units, qualifying circumstances, limitations/exclusions, and reimbursement rules for anesthesia services billed to Blue Cross and Blue Shield of Texas. Applies to professional in-network providers submitting CMS 1500 claims for anesthesia services effective August 14, 2024 (BCBSTX).

Policy Summary

PayerBlue Cross Blue Shield - Texas

PolicyCpcp010 Anesthesia 08142024

Policy CodePolicy CPCP010

Change TypeRevised (Version 2.0)

Effective DateAug 14, 2024

Next Review Date

Key ActionWhen multiple procedures occur during a single anesthesia administration, report only the single anesthesia code with the highest Base Unit Value plus combined time for all procedures; exceptions apply for specified add-on anesthesia codes.

SourceLink

POLICY UPDATE CHANGES

Enterprise Clinical Payment and Coding Policy Committee Approval Date: February 22, 2024; Plan Effective Date: August 14, 2024 (BCBSTX).

4Qualifying circumstance CPT codes listed

00100-01999General anesthesia code range referenced

01996Daily management code referenced

Policy summary and scope

Coverage and payment rules

Payment calculation for in-network professional anesthesia providers

Total units allowed when paid based on time and points methodology:

ALL of the following

Calculation formula: Total units allowed = (Time Units + Base Units Value) x Conversion Factor
Time unit definition: Time units are based on 15-minute increments15-minute increments
Time begin/end: Time begins when provider physically starts to prepare patient for induction in the OR (or equivalent) and ends when provider no longer in constant attendance and patient may be safely placed under postoperative supervision
Base points guidance: Base points determined by ASA Relative Value Guide in effect on date of service; newly established codes paid at determined rates until updated
Add-on handling: Qualifying circumstance add-on values allowed = Qualifying Circumstance Value x Conversion Factor; add-ons billed only with anesthesia service with highest Base Unit Value

Qualifying circumstances (add-on CPT codes and unit values)

ALL of the following

CPT 99100 — ANESTHESIAUnit Value = 1
CPT 99116 — ANESTHESIA, LOW BODY TEMPUnit Value = 5
CPT 99135 — ANESTHESIA, LOW BLOOD PRESSUREUnit Value = 5
CPT 99140 — ANESTHESIA IN EMERGENCYUnit Value = 2

Included in base unit value (not separately reimbursable)

The following are included in the base unit value and not eligible for separate reimbursement:

ALL of the following

Pre/post visits: Preoperative and postoperative visits
Fluids/blood: Administration of fluids and/or blood products incident to anesthesia care (including venipuncture/needle or catheter introduction)
Laryngoscopy/bronchoscopy: Laryngoscopy and/or bronchoscopy
Retrobulbar injection

Daily hospital management of continuous epidural/subarachnoid drug administration (CPT 01996)

When applicable:

ALL of the following

01996 description: CPT 01996 is for daily hospital management after insertion of epidural/subarachnoid catheter
Same-date inclusion: 01996 is included in the initial procedure if submitted on same date of service by same qualified provider
Daily base units only: Only base units allowed each day; time or service units are not used to determine reimbursement

Multiple or duplicate anesthesia services on same day

ALL of the following

Single highest-base-unit code: For multiple surgical procedures during a single anesthesia administration, report only single anesthesia code with highest Base Unit Value plus combined time for all procedures
Exceptions for add-on codes: Exceptions: add-on anesthesia codes such as 01953, 01968, 01969
Denial of secondary services: If multiple general anesthesia codes (00100-01999) submitted, highest submitted charge eligible; secondary anesthesia services denied
Duplicate submissions reimbursed once: If duplicate anesthesia codes reported by same or different provider for same patient/date, Plan reimburses only first submission of that code

Modifier 22 (increased procedural services / field avoidance)

Modifier 22 use

Documentation requirement: Documentation must support substantial additional work and reason
All conditions must be met note: all conditions must be met
Additional payment conditions group
- Anesthesia record documentation: Documentation included in member's anesthesia record
- Base unit threshold: Base unit is less than 5 units

Tumescent anesthesia

ALL of the following

Tumescent anesthesia is included in endovenous ablations and is not separately reimbursable

Code lists and modifier guidance

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

Daily hospital managementCPTCovered

01996

Daily hospital management of epidural or subarachnoid continuous drug administration - base units only

General anesthesia code range (payment rules apply)CPTCovered

00100-01999

General anesthesia codes; when multiple general anesthesia codes submitted, highest base unit valued code billed and secondary services denied; exceptions for specified add-on codes (e.g., 01953, 01968, 01969)

Add-on anesthesia codes (examples/exceptions)CPTCovered

01953	Add-on anesthesia code - example exception to single-code rule
01968	Add-on anesthesia code - example exception to single-code rule
01969	Add-on anesthesia code - example exception to single-code rule

Anesthesia modifiers (first modifier position 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 by an anesthesiologist
QX	CRNA service with medical direction by a physician
QZ	CRNA service: without medical direction by a physician

Anesthesia modifiers (second modifier position examples)Modifier

QS	Monitored anesthesia care service
G8	Monitored anesthesia care for deep complex, complicated, or markedly invasive surgical procedure
G9	Monitored anesthesia care for a patient with history of severe cardiopulmonary condition
GC	Service performed in part by a resident under direction of teaching physician
GE	Service performed by a resident without 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 required anesthesia modifiers in the first modifier position (for example AA, AD, QK, QY, QX, QZ) to identify whether the service was personally performed, supervised, or directed; use second-position modifiers (for example QS, G8, G9, GC, GE, GF, 22, 23, 47) to convey additional context such as monitored anesthesia care, resident involvement, or unusual circumstances. Report simultaneous physician and CRNA services with the appropriate modifiers and follow the provider_actions guidance for modifier use and duplicate submissions.

Billing, documentation, and submission requirements

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 plus combined time for all procedures; exceptions are specified add-on anesthesia codes.

Affected codes: 00100-01999
Exceptions (add-on codes): 01953, 01968, 01969

Billing Rule

Duplicate code submissions

If duplicate anesthesia codes are billed by the same or different providers for the same patient/date, the Plan reimburses only the first submission of that code. Anesthesia administration services provided simultaneously by a physician and a CRNA during the same operative session must be reported with the appropriate modifiers.

Plan reimburses only the first submission of a duplicate anesthesia code (same patient/date).
When physician and CRNA provide services simultaneously, report both with appropriate modifiers (per anesthesia modifier guidance).

Documentation Required

Support Modifier 22 claims

Support Modifier 22 claims by documenting the substantial additional work and reason in the member's anesthesia record. Additional payment for field avoidance is allowed only when all required documentation and conditions are met.

Include the member's anesthesia record documenting the substantial additional work and reason.
Base unit value must be less than 5.
Procedure is performed around the head, neck, or shoulder girdle and/or the position requires other than supine.

Billing Rule

CPT 01996 daily management billing

CPT 01996 (daily hospital management of epidural/subarachnoid drug administration) is included in the initial procedure when submitted on the same date of service by the same qualified provider; when billed for daily management, only base units are allowed each day and time/service units are not used to determine reimbursement.

01996 included if submitted same date by same provider.
Only base units allowed each day; time/service units not used for reimbursement.

Billing Rule

Modifier use for provider type and supervision

Append the required first-position anesthesia modifiers to identify whether the service was personally performed, supervised, or directed; use second-position modifiers as applicable to describe monitoring, residency status, increased services, or other special circumstances.

First-position modifiers (when applicable): AA, AD, QK, QY, QX, QZ
Second-position examples: QS, G8, G9, GC, GE, GF, 22, 23, 47

Documentation Required

Claims documentation and accuracy

Providers must submit accurate coding and documentation using HIPAA‑approved code sets and appropriate code combinations per industry coding guidelines. The Plan may request additional documentation upon review.

Use valid HIPAA-approved code sets and industry-standard coding guidelines when reporting services.
Additional documentation may be requested by the Plan to support claims.

OpenPayer

Cpcp010 Anesthesia 08142024

Policy summary and scope

Coverage and payment rules

Code lists and modifier guidance

Billing, documentation, and submission requirements

Key terms

Policy changes and review timeline