ModifiedEmblemHealthPolicy RPC20210013

Anesthesia (Commercial/Medicare/Medicaid)

EmblemHealth reimbursement policy for anesthesia services (Commercial/Medicare/Medicaid) defining coding, time reporting, unit calculation, modifier reimbursement percentages, bundling rules, duplicate/multiple service rules, and specific guidance for neuraxial labor analgesia, obstetric add-on codes, and CPT exceptions (01953, 01996). Applies to claims submitted on CMS 1500/837P.

Policy Summary

PayerEmblemHealth

PolicyAnesthesia (Commercial/Medicare/Medicaid)

Policy CodePolicy RPC20210013

Change TypeRevisions and clarifications (billing instructions, exceptions, modifier guidance)

Effective DateJan 1, 2021

Next Review Date

Key ActionSubmit claims using the individual provider NPI, bill anesthesia CPT codes in minutes with start/end times, and apply the appropriate anesthesia modifier in the first modifier field.

SourceLink

POLICY UPDATE CHANGES

Transferred policy content to individual company-branded template on 10/10/2025.

Updated 'Billing Instructions' with clarifying language regarding multiple anesthesia sessions on the same date of service (2/2024).

Updated Policy Overview to include/clarify time-based exception when reporting 01953 and 01996 (10/2022).

Added clarification that services appended with Physical Status (P) Modifiers are not eligible for reimbursement for EmblemHealth Medicare and Medicaid plans (8/25/2021).

Aligned with ASA guidelines to support a maximum payment cap of 435 minutes for neuraxial labor anesthesia (10/05/2020).

00100-01999

Anesthesia CPT code range applicable

435Neuraxial labor analgesia cap

15Anesthesia time unit conversion (minutes)

99100/99116/99135/99140Qualifying circumstance codes bundled

Policy overview

EmblemHealth's anesthesia reimbursement policy follows CMS NCCI policy and edits, the CMS National Physician Fee Schedule, and ASA guidance to define how anesthesia services (CPT 00100-01999, excluding 01953 and 01996) are coded and paid for Commercial, Medicare and Medicaid lines of business. Claims must be submitted on the CMS 1500 / 837P format using the individual provider NPI with the appropriate anesthesia modifier in the first modifier field, report actual anesthesia time in minutes (with start/end times in claim Notes or box 24A), and use EmblemHealth's Standard Anesthesia Formula to convert minutes to time units (minutes ÷ 15 = time units) and calculate allowance as (Base Units + Physical Status + Time) × Conversion Factor. Modifier reimbursement percentages (e.g., AA 100%, QK/QY/QX/AD 50%, QZ 100%) and the policy's treatment of Physical Status modifiers (P3–P5 unit values noted but no additional reimbursement for P modifiers for EmblemHealth Medicare and Medicaid) are specified. The policy addresses bundling rules and duplicate/multiple service rules (only the highest base unit procedure is paid for multiple procedures in one anesthesia session; duplicate same-code submissions reimbursed only once; separate non-sequential sessions require documentation), procedures considered bundled or included in anesthesia or procedural payments, rules for E/M and critical care, and special provisions for daily hospital management (01996—separately reimbursable once per DOS in specified hospital POS with exceptions) and neuraxial labor analgesia and obstetric add-ons (01967 reimbursed with a cap of 435 minutes; 01968/01969 reimbursable as add-ons with time reported separately and same DOS requirement).

Effective Date2021-01-01

Last Review2025-10-10

Next Review

Policy NumberRPC20210013

SubjectAnesthesia billing and reimbursement rules

Applies toEmblemHealth reimbursement policy for anesthesia services (Commercial/Medicare/Medicaid) defining coding, time reporting, unit calculation, modifier reimbursement percentages, bundling rules, duplicate/multiple service rules, neuraxial labor analgesia and obstetric add-on guidance; applies to claims submitted on CMS 1500/837P.

Billing & reimbursement rules (actionable)

General billing and reimbursement requirements

Anesthesia services billed with CPT codes 00100-01999 (excluding 01953 and 01996) are reimbursed as time-based using the Standard Anesthesia Formula. Claims must meet the following:

Provider and modifier submission: Submit claims using the provider NPI for the individual provider and apply the appropriate anesthesia modifier in the first modifier field.
Minutes and time units: Report anesthesia CPT codes in minutes representing duration of service; EmblemHealth divides minutes billed by 15 to determine time units (anesthesia unit equivalent).Minutes/15
Start and end times: Provide 'start' and 'end' times in the Notes section of electronic claim or box 24A on paper claim.

Code lists

Anesthesia CPT range (time-based)CPTCovered

00100-01999

Anesthesia CPT codes billed in minutes and reimbursed as time-based using Standard Anesthesia Formula; excludes 01953 and 01996 for time-based reporting exception.

Excluded from time-based anesthesia reportingCPT

01953	Not considered anesthesia services for time-based reporting (exception).
01996	Daily hospital management code; special separate reimbursement rules apply (separately reimbursable once per date of service in specified hospital POS excluding day of insertion).

Qualifying circumstance codes (bundled, not separately reimbursable)CPTNot Covered

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 obstetric anesthesia codesCPTCovered

01967	Neuraxial labor analgesia (base units plus time; subject to 435-minute cap).
01968	Add-on c-section anesthesia (add-on to 01967); time reported separately and not added to labor anesthesia time.
01969	Add-on c-section anesthesia (add-on to 01967); time reported separately and not added to labor anesthesia time.

Modifiers with specified reimbursementModifier

AA	Anesthesia services performed personally by the anesthesiologist - 100% reimbursement
AD	Medical supervision by a physician; >4 concurrent - 50% reimbursement
QK	Medical direction of 2-4 concurrent anesthesia procedures - 50% reimbursement
QX	CRNA with medical direction by physician - 50% reimbursement
QY	Medical direction of one qualified non-physician anesthetist - 50% reimbursement
QZ	CRNA service without medical direction - 100% reimbursement
P1	Physical status modifier - 0 units
P2	Physical status modifier - 0 units
P3	Physical status modifier - 1 unit
P4	Physical status modifier - 2 units

1–10 of 18

1/2

Modifiers for additional anesthesia sessions same dayModifierCovered

59	Distinct procedural service - used to append additional anesthesia administration on same day
76	Repeat procedure by same physician - used for additional anesthesia session
77	Repeat procedure by another physician - used for additional anesthesia session
78	Return to OR for related procedure - used for additional anesthesia session
79	Unrelated procedure or service by same physician during postoperative period - used for additional anesthesia session
XE	Separate encounter - used to append additional anesthesia administration on same day

Provider actions & billing callouts

Billing Rule

Report individual provider NPI and anesthesia modifier

Submit claims using the provider NPI for the individual provider and apply the appropriate anesthesia modifier in the first modifier field.

Billing Rule

Report actual anesthesia minutes and start/end times

Anesthesia CPT codes must be billed in minutes representing duration; include start and end times in claim Notes or box 24A.

Provide start and end times in Notes (electronic claim) or box 24A (paper claim).

Definitions

Same Individual Physician or Other Qualified Health Care ProfessionalThe same individual rendering health care services reporting the same Federal Tax Identification number.

Same Specialty Physician or Other Qualified Health Care ProfessionalPhysicians and/or other qualified health care professionals of the same group and same specialty reporting the same Federal Tax Identification number.

Policy revision history

10/10/2025AdministrativeLatest

Transferred policy content to individual company-branded template; no changes to policy title or policy number.

2/2024Material

Updated 'Billing Instructions' with clarifying language regarding multiple anesthesia sessions on the same date of service.

10/2022Material

Updated Policy Overview to include/clarify time-based exception when reporting CPT codes 01953 and 01996.

Policy Summary

PayerEmblemHealth

PolicyAnesthesia (Commercial/Medicare/Medicaid)

Policy CodePolicy RPC20210013

Change TypeRevisions and clarifications (billing instructions, exceptions, modifier guidance)

Effective DateJan 1, 2021

Next Review Date

Key ActionSubmit claims using the individual provider NPI, bill anesthesia CPT codes in minutes with start/end times, and apply the appropriate anesthesia modifier in the first modifier field.

SourceLink

On This Page

Non-anesthesia / qualifying circumstance units: CPT codes for non-anesthesia services, including Qualifying Circumstances, should be billed as one unit; do not bill minutes for these codes.

Multiple anesthesia services - highest base units: When more than one anesthesia service is billed same date, base units reimbursed only for procedure with highest base unit; lesser procedures reimbursed for time only.

Separate non-sequential sessions: When multiple anesthesia services on same date are due to separate non-sequential anesthesia sessions, clinical documentation is required on appeal to reimburse base units plus time for separate session.

Duplicate code rule: When duplicate (same) anesthesia codes are reported by same or different providers for same patient/date, only the first submission of that code will be reimbursed.

Additional anesthesia administration same day: Anesthesia administration services provided during a different operative session on same day as previous session will be reimbursed as one additional anesthesia administration appended with modifier 59, 76, 77, 78, 79 or XE.

Anesthesia unit and allowance calculation

Standard Anesthesia Calculation used to determine allowance:

Allowance formula: Allowance = (Base Units + Physical Status + Time) x Anesthesia Conversion Factor.
Base units per CPT: Each CPT anesthesia code is assigned a Base Value; EmblemHealth follows CMS anesthesia base units by CPT code.
Actual minutes required: EmblemHealth requires actual anesthesia time in minutes reported on the claim (per CMS guidance).

Modifier reimbursement rules

Reimbursement percentages and handling for common anesthesia modifiers:

AA (anesthesia services performed personally by the anesthesiologist) reimbursed at 100% of allowance.100%
AD (medical supervision by a physician; more than four concurrent) reimbursed at 50% of allowance.50%
QK (medical direction of 2-4 concurrent anesthesia procedures) reimbursed at 50% of allowance.50%
QX (CRNA with medical direction by physician) reimbursed at 50% of allowance.50%
QY (medical direction of one qualified non-physician anesthetist) reimbursed at 50% of allowance.50%
QZ (CRNA service without medical direction) reimbursed at 100% of allowance.100%
Physical status modifiers: P3, P4, P5 may be billed for additional minutes added to anesthesia code to represent corresponding units; report in second modifier field.
Medicare/Medicaid P-modifier non-recognition: EmblemHealth aligns with CMS and does not recognize or issue additional reimbursement for Physical Status (P) modifiers for Medicare and EmblemHealth Medicaid plans.

Qualifying circumstances (bundled codes)

Qualifying circumstance codes are bundled and not separately reimbursable:

Bundled status: EmblemHealth does not allow separate reimbursement for qualifying circumstance codes; these are assigned status indicator 'B' and are included in primary anesthesia RVUs.
Not reimbursable qualifying circumstance codes include
- 99100: Anesthesia for patient of extreme age (younger than 1 year and older than 70).
- 99116: Anesthesia complicated by utilization of total body hypothermia.
- 99135: Anesthesia complicated by utilization of controlled hypotension.
- 99140: Anesthesia complicated by emergency conditions.

Bundling between anesthesia and procedural/pain services

Bundling rules when anesthesia and procedural/pain services are performed by the same individual (Same Individual defined by same Federal Tax ID):

Same Individual bundling rule: Procedural/pain management services or anesthesia services identified as bundled are not separately reimbursable when performed by the Same Individual Physician or Other Qualified Health Care Professional on same date of service (Same Individual defined by same Federal Tax ID).
Examples of procedural/pain services bundled in anesthesia: Procedural/pain services bundled in anesthesia services include: CMS Physician Fee Schedule status indicator B codes; services with status N or T (Injections); and nerve block codes billed with anesthesia when modifier 59, XE or XU is not appended to the nerve block code.
Anesthesia bundled in procedural services and modifier 47 guidance: CMS/NCCI rules do not allow separate payment for anesthesia services performed by the physician who also furnishes the medical/surgical procedure (excluding moderate sedation). Modifier 47 is appended to the surgical code when the physician personally performs anesthesia and no anesthesia section codes are used.

Pre/Postoperative visits and critical care

Payment rules for E/M services reported with anesthesia (same specialty same group rules):

E/M with anesthesia exclusion: EmblemHealth will not separately reimburse an E/M service (excluding critical care CPT codes 99291-99292) when reported by the Same Specialty Physician or Other Qualified Health Care Professional on the same date of service as an anesthesia service.
Critical care exception: Critical care CPT codes 99291-99292 are not considered included in an anesthesia service and will be separately reimbursed.

Daily hospital management (01996)

Payment rules specific to CPT code 01996 (daily hospital management):

Once-per-date reimbursement: 01996 in CMS POS 19, 21, 22 or 25 is separately reimbursable once per date of service excluding the day of insertion.
Included when same provider submits with pain management: CPT code 01996 is considered included in the pain management procedure if submitted same date by the Same Individual Physician or Other Qualified Health Care Professional.
Post-discharge care: If the anesthesiologist continues care after discharge, use appropriate E/M code.

Neuraxial labor analgesia and obstetric add-on codes

Rules for neuraxial labor analgesia (01967) and obstetric add-on codes (01968, 01969):

01967 reimbursement and cap: Neuraxial labor analgesia (01967) reimbursed based on Base Unit Value plus Time Units subject to a reasonable cap of 435 minutes.435 minutes
Modifying units inclusion: Modifying Units for physical status modifiers and qualifying circumstance codes will be considered in addition to Base Unit Value for labor or delivery anesthesia services per the Standard Anesthesia Formula.
Add-on 01968/01969 handling: EmblemHealth will consider add-on CPT codes 01968 and 01969 when billed with primary CPT 01967; time for add-on code is reported separately and is not added to labor anesthesia time.
Date-of-service consistency for add-ons: All add-on services must be reported with a date of service consistent with the date of service of primary CPT 01967.

Billing Rule

Time unit calculation

EmblemHealth divides minutes billed by 15 to calculate anesthesia time units and adds to base units per Standard Anesthesia Formula.

Minutes divided by 15 = time units

Documentation Required

Separate non-sequential anesthesia sessions

Provide clinical documentation on appeal when multiple anesthesia services on same date are due to separate non-sequential sessions to support reimbursement of base units plus time for the separate session.

Clinical documentation required on appeal to reimburse base units plus time for the separate session.

Billing Rule

Duplicate code submission

Only the first submission of the same anesthesia code for the same patient and date of service will be reimbursed; simultaneous MD and CRNA sessions require appropriate Q-modifiers to split payment.

Use QK/QY and QX (or other appropriate Q-modifiers) to split payment when MD and CRNA provide simultaneous services so each receives the applicable percentage.

Billing Rule

01996 daily management billing

01996 is separately reimbursable once per date of service (excluding the day of insertion) in specified hospital place-of-service codes; considered included if submitted same date by same provider as pain management procedure.

Report 01996 in CMS POS 19, 21, 22 or 25; reimbursable once per date of service excluding insertion day.

Billing Rule

Obstetric add-on coding

01968 and 01969 may be reimbursed when billed with primary 01967 for same member; time for add-on codes is reported separately and add-on services must have date of service consistent with primary 01967.

Add-on times are reported separately and must match the date-of-service of primary code 01967.

Denial Risk

Qualifying circumstance codes not separately reimbursable

Claims reporting qualifying circumstance codes (e.g., 99100, 99116, 99135, 99140) as separate payable items may be denied because these are considered bundled into the primary anesthesia RVUs.

Examples of denial-risk codes: 99100, 99116, 99135, 99140

8/25/2021Material

Clarified that services appended with Physical Status (P) Modifiers are not eligible for additional reimbursement for EmblemHealth Medicare and Medicaid plans.

10/05/2020Material

Aligned with ASA guidelines to support a maximum payment cap of 435 minutes for neuraxial labor anesthesia and removed prior Obstetric Anesthesia Services section.