CurrentBlue Cross Blue Shield - WisconsinPolicy N/A

Professional Anesthesia Services (MA PPO)

This policy governs how Anthem Blue Cross and Blue Shield Medicare Advantage reimburses professional anesthesia services, including time reporting, modifiers, qualifying circumstances, included/excluded services, postoperative pain management, billing rules for multiple procedures, and coding relationships. It applies to participating providers and facilities and references ASA methodology and NCCI edits.

Policy Summary

PayerBlue Cross Blue Shield - Wisconsin

PolicyProfessional Anesthesia Services (MA PPO)

Policy CodePolicy N/A

Change TypeRevised (biennial review)

Effective DateNov 25, 2020

Next Review DateN/A

Key ActionReport anesthesia services in one-minute increments, calculate time units by dividing minutes by 15 and rounding to the nearest tenth, and document start and stop times in the medical record.

SourceLink

POLICY UPDATE CHANGES

Last Approval Date: 09/22/2021; Effective Date: 11/25/2020

SeveralCode groups addressed (CPT/CDT/Modifiers)

5Minimum base units for field avoidance

50%Reimbursement percent when QK/QX/QY appended

Policy summary

This policy governs Anthem Medicare Advantage professional anesthesia reimbursement and is based on the American Society of Anesthesiologists (ASA) anesthesia formula and ASA RVG-derived base units, incorporating applicable NCCI, CMS, AMA CPT, and AAPC/HCPCS guidance. It applies to participating providers and facilities and covers the core topics necessary for accurate claim submission and reimbursement calculation including time reporting and time unit calculation, modifier use and placement (servicing/performer modifiers and informational MAC modifiers), qualifying circumstance codes, services included or excluded from the global anesthesia payment, postoperative pain management billing, and rules for multiple procedures and add-on anesthesia codes.

Policy metadata and thresholds

Effective Date2020-11-25

Last Review2021-09-22

Next Review

Policy NumberN/A

Scope SummaryGoverns Anthem Medicare Advantage reimbursement for professional anesthesia services including time reporting, modifiers, qualifying circumstances, included/excluded services, postoperative pain management, multiple procedure billing and ASA methodology/NCCI edits.

StatusCURRENT

Time unit calculationMinutes reported divided by 15 and rounded to the nearest tenth

Minimum base value (field avoidance/unusual positioning)5 base units

Coverage rules and criteria

Time reporting and unit calculation

Anesthesia time and unit calculation rules:

Providers must report anesthesia services in one-minute increments and note minutes in the units field.

To calculate reimbursement for time, the number of minutes reported is divided by 15 and rounded to the nearest tenth to provide a time unit.Minutes reported divided by 15 and rounded to nearest tenth

Anesthesia time starts with preparation of the member for administration of anesthesia and stops when the anesthesia provider is no longer in personal attendance.

Start and stop times must be documented in the member's medical record.

Anesthesia time can be counted in blocks if there is interruption, provided counted time is continuous anesthesia service time.

Anesthesia claims submitted with an indicator other than minutes may be rejected or denied.

Modifiers and provider relationships

Rules for modifier placement and combined provider reimbursement:

Anesthesia modifiers identifying who performed the anesthesia must be billed in the primary modifier field to receive appropriate reimbursement.

Modifiers G8, G9, or QS may be reported in a subsequent modifier field when the service rendered is monitored anesthesia care (MAC).

Claims submitted without the appropriate modifier will be denied.

Total reimbursement for anesthesia services provided by a physician/anesthesiologist and a non-physician anesthesia provider will not exceed 100% of the eligible amount that would be allowed had the service been provided by only the physician/anesthesiologist.

Physical status modifiers (P3-P5 etc.) are assigned unit values per ASA recommendations and these units may need to be added when appending modifiers (note: system limitations may require providers to add units).

Multiple procedures

When multiple surgical procedures are performed:

Only the anesthesia procedure code for the most complex service should be reported; base units are only used for the primary procedure and not for secondary procedures.

If two separate anesthesia codes are reported, the procedure with the lesser charge will be denied.

Exception: Add-on codes 01953, 01968, and 01969 are eligible for separate reimbursement in addition to the primary procedure code.

If Anthem determines a separate subsequent operative session occurred with more than an hour separation from the initial anesthesia, the second anesthesia service may be eligible for separate reimbursement.

Field avoidance and unusual positioning

Minimum base value requirement for special positioning/field avoidance:

Procedures requiring field avoidance or positions other than supine or lithotomy must have a minimum base value of 5 regardless of any lesser base value assigned to the procedure.Minimum base value = 5 base units

Field avoidance is not eligible for additional reimbursement even when reported with modifier 22.

Qualifying circumstances (additional codes eligible)

Qualifying circumstance codes that may be reported in addition to the base anesthesia code:

Qualifying circumstance CPT codes: 99100: Anesthesia for patient of extreme age, younger than one year and older than 70

Qualifying circumstance CPT codes: 99116: Anesthesia complicated by utilization of total body hypothermia

Qualifying circumstance CPT codes: 99140: Anesthesia complicated by emergency conditions (eligible for separate reimbursement except when reported for an unscheduled routine obstetric delivery with specified diagnosis codes)

Qualifying circumstance CPT codes: 99135: Anesthesia complicated by utilization of controlled hypotension

Oral surgery anesthesia

Rules when both CDT and CPT anesthesia codes are reported for oral surgery:

Anthem allows reimbursement for anesthesia for covered oral surgical procedures when reported with appropriate CDT-based anesthesia codes (D9210-D9248).

CDT anesthesia codes D9210-D9248 will not be eligible for separate reimbursement when reported with CPT procedure codes.

CPT anesthesia codes 00170-00176 that describe anesthesia for intraoral procedures will not be eligible for reimbursement when reported with CDT procedures.

When an oral surgeon reports services with a CPT procedure and also provides an anesthesia service, modifier 47 must be appended; in this instance there is no additional reimbursement (only the covered oral surgery procedure is eligible for reimbursement).

Services included/excluded in global anesthesia reimbursement

Services considered included in global anesthesia payment and services eligible for separate reimbursement:

Global reimbursement includes all procedures integral to anesthesia administration from initial pre-anesthesia evaluation through when the anesthesia provider is no longer in personal attendance.

Included (not separately reimbursable) services: echocardiography (when part of anesthesia), inhalation treatments, EEG, laryngoscopy and bronchoscopy, placement of endotracheal and nasogastric tubes, placement and interpretation of non-invasive monitoring (ECG, temperature, BP, pulse oximetry, CO2 monitoring, capnography, mass spectrometry, vital capacity), peripheral IV lines and administration of fluids/medications, venipuncture and transfusion, daily hospital management of patient-controlled analgesia (when patient controls analgesia).

One-day preoperative and 10-day postoperative E/M services related to the surgical episode are considered included in global reimbursement for the anesthesia service; the 10-day postoperative period applies to the anesthesiologist or other qualified professional in same anesthesia group.

Nerve block injections for pain management are eligible for separate reimbursement (see postoperative pain management section).

Postoperative pain management (separate reimbursement rules)

Which pain management services are separately reimbursable and how:

Postoperative management services by an anesthesiologist such as injection or catheter insertion into epidural space or major nerve are eligible for separate reimbursement and time units are not applicable.

Applicable code ranges eligible: 62320-62327, 64413-64425, and 64445-64450.

When postoperative management services are performed bilaterally, report the unilateral code once with modifier 50; the pain management code will be considered one surgical service and eligible for reimbursement equal to 150% of the allowance for the code.150% reimbursement for bilateral when reported with modifier 50

An epidural or major nerve injection or catheter insertion performed by an anesthesiologist for postoperative management before, during, and/or following the surgical procedure is eligible for separate reimbursement in addition to the primary anesthesia code; append appropriate modifier to indicate distinct procedural service.

Code lists and modifier guidance

Qualifying circumstance CPT codes (eligible additional codes)CPTCovered

99100	Anesthesia for patient of extreme age
99116	Anesthesia complicated by utilization of total body hypothermia
99135	Anesthesia complicated by utilization of controlled hypotension
99140	Anesthesia complicated by emergency conditions

Add-on anesthesia codes eligible as exceptionsCPTCovered

01953	Add-on anesthesia code eligible for separate reimbursement
01968	Add-on anesthesia code eligible for separate reimbursement
01969	Add-on anesthesia code eligible for separate reimbursement

Postoperative pain management codes (eligible separate reimbursement)CPTCovered

62320-62327	Epidural injection/catheter codes (postoperative management)
64413-64425	Nerve block injection codes
64445-64450	Peripheral nerve block codes
01996	Daily hospital management of epidural/subarachnoid continuous drug administration

Transesophageal echocardiography (TEE) codesCPT

93312-93317	TEE codes - may be eligible for separate reimbursement if distinct and independent and appropriate modifier appended
93318	TEE monitoring - considered incidental, not separately reimbursable per NCCI
93355	TEE for guidance of transcatheter interventions - considered incidental per NCCI

Oral surgery CDT anesthesia codes (facility anesthesia)NDC|mixedCovered

D9210-D9248

CDT anesthesia codes for oral surgery (allowed when reported alone)

CPT intraoral anesthesia codes (not reimbursed with CDT)CPTNot Covered

00170-00176

Anesthesia for intraoral procedures - not eligible when reported with CDT procedures

Medication charges reported by professional provider in facilityHCPCS|CPT|mixedNot Covered

*	Any medication (including Propofol) separately reported by professional provider in a facility setting is not eligible for separate reimbursement even when reported with an unclassified/unspecified drug code

Modifiers required in first modifier field (pay percent modifiers)Modifier

AA	Anesthesiologist performed service - pay percent modifier (must be first modifier field)
AD	Medical supervision by anesthesiologist - pay percent modifier
QK	Medical direction of two or more CRNAs - pay percent modifier (50% reduction for certain codes applies)
QX	CRNA service with medical direction - pay percent modifier
QY	Anesthesia service performed by an anesthesiologist with one CRNA - pay percent modifier
QZ	CRNA service without medical direction - pay percent modifier
G8	Monitored anesthesia care for deep sedation/analgesia - informational, may be reported in subsequent modifier field
G9	Monitored anesthesia care for moderate sedation/analgesia - informational
QS	Monitored Anesthesia Care (MAC) - informational

Modifiers that identify who performed the anesthesia (for example AA, AD, QK, QX, QY, QZ) must be billed in the primary modifier field to receive appropriate reimbursement; informational modifiers for monitored anesthesia care (G8, G9, QS) may be appended in a subsequent modifier field. Claims submitted without the appropriate primary modifier or without minutes may be denied.

Billing, documentation & denial risks

Billing Rule

Report anesthesia time in minutes

Report anesthesia services in one-minute increments and record minutes in the units field. For reimbursement, divide reported minutes by 15 and round to the nearest tenth to determine time units. Start and stop times must be documented in the member's medical record.

Report anesthesia time in one-minute increments.
Calculate time units by dividing minutes by 15 and rounding to the nearest tenth.
Document anesthesia start and stop times in the medical record.

Billing Rule

Place provider-identifying modifiers in primary modifier field

Append modifiers that identify who performed the anesthesia in the primary (first) modifier field to receive appropriate reimbursement. Monitored anesthesia care modifiers (G8, G9, QS) may be reported in a subsequent modifier field.

Billing Rule

Do not bill medications separately in facility setting

Medications reported separately by a professional provider in a facility setting are not eligible for separate reimbursement. This includes Propofol and applies even when reported with an unclassified/unspecified drug code.

Billing Rule

Multiple anesthesia procedures billing

When multiple surgical procedures are performed, report only the anesthesia code for the most complex service; if two separate anesthesia codes are reported the lesser procedure will be denied. Exceptions exist for specific add-on anesthesia codes which may be reported in addition to the primary procedure.

Exception add-on codes: 01953, 01968, 01969
If two anesthesia codes are reported, the lesser of the two reported anesthesia codes will be denied (except for listed add-on codes).

Billing Rule

TEE modifier requirements

If transesophageal echocardiography (TEE) in the 93312-93317 range is performed as a distinct, independent procedure, append the appropriate modifier to the TEE code to be eligible for separate reimbursement. TEE monitoring/guidance codes (for example 93318 and 93355) are considered incidental per NCCI and a bypass modifier will not override NCCI edits.

Affected codes: 93312-93317, 93318, 93355
TEE monitoring/guidance codes typically considered incidental and modifier will not override NCCI edits.

Denial Risk

Claims missing appropriate modifiers may be denied

Claims submitted without appropriate anesthesia modifiers or without minutes may be rejected or denied. Anthem may recover, recoup, or adjust payments if billing guidelines are not followed.

Billing Rule

Postoperative pain management billing

Postoperative pain management services (e.g., epidural or major nerve injection/catheter insertion) are eligible for separate reimbursement; time units do not apply. Daily management of epidural/subarachnoid continuous drug administration (01996) is allowed once per date of service following surgery but is not payable when reported with an anesthetic injection code. Bilateral services should be reported with modifier 50 and will be reimbursed at 150% of the allowance. When QK, QX, or QY is appended to applicable spinal/nerve injection codes, a 50% reimbursement percentage applies.

Affected codes: 62320-62327, 64413-64425, 64445-64450, 01996
01996 is allowed once per date of service following surgery; when billed with an injection code (e.g., 62320-62327) only the injection code is eligible for reimbursement.
Report bilateral procedures once with modifier 50; reimbursement equals 150% of the allowance.
When modifier QK, QX, or QY is appended to an applicable injection code, reimbursement percentage is 50%.

Key terms

Definitions

Base Units (BU)Base Units assigned to a specific anesthesia CPT code derived from the ASA Anesthesia Relative Value Guide.

Conversion Factor (CF)A single unit rate used in the calculation for anesthesia reimbursement.

Time Units (TU)An increment of fifteen (15) minutes where each 15-minute increment constitutes one time unit.

General/Regional/Local AnesthesiaGeneral: affects entire body with loss of consciousness; Regional: loss of sensation in a region; Local: loss of sensation in a limited area.

Document changes and history

2020-11-25effective_date

Effective Date: 11/25/2020

2021-09-22approval_date

Last Approval Date: 09/22/2021

2020-11-25revisionLatest

Biennial review with definition updates and policy language changes (definition section updated and language changes)

Policy Summary

PayerBlue Cross Blue Shield - Wisconsin

PolicyProfessional Anesthesia Services (MA PPO)

Policy CodePolicy N/A

Change TypeRevised (biennial review)

Effective DateNov 25, 2020

Next Review DateN/A

SourceLink

On This Page

Anthem will determine mutually exclusive relationships between qualifying circumstance codes and base anesthesia codes; some relationships may prevent separate reimbursement.

Medication reporting in facility: When a professional provider separately reports a medication in a facility setting, the medication will not be eligible for separate reimbursement even when reported with an unclassified/unspecified drug code; medications (including Propofol) are considered included under the facility's charge.

Central venous pressure line insertion, Swan-Ganz catheter insertion, and intra-arterial lines are eligible for separate reimbursement when provided in conjunction with anesthesia procedures.

TEE separate reimbursement guidance: If TEE (CPT 93312-93317) is performed as a distinct and independent procedure from anesthesia, the appropriate modifier must be appended to be eligible for separate reimbursement; TEE monitoring codes (e.g., 93318) or guidance codes (e.g., 93355) follow NCCI and are considered incidental and not separately reimbursable; modifier will not override NCCI edits.

Daily hospital management of epidural or subarachnoid continuous drug administration (CPT 01996) is eligible for reimbursement once per date of service following the surgery date; when 01996 is reported with an anesthetic injection code (e.g., 62320-62327), only the injection code is eligible for reimbursement; modifiers will not override the edits.01996 paid once per date of service following surgery; not paid with injection code

QK/QX/QY modifier effect: When modifier QK, QX, or QY is appended to an applicable spinal/nerve injection code (e.g., 60000 series postoperative management/nerve block procedures), a reimbursement percentage of 50% will apply.50% reimbursement when QK/QX/QY appended

Anthem will deny daily hospital management code when billed with a physical status modifier or qualifying circumstance procedure codes.