ModifiedEmpire BluecrossPolicy C-09002

Anesthesia Services Professional, Commercial Reimbursement Policy

Defines Anthem/Empire BlueCross commercial reimbursement rules for professional anesthesia services including coding, time reporting, modifiers, included/excluded services, and special situations; applies to professional providers submitting claims under commercial benefit plans.

Policy Summary

PayerEmpire Bluecross

PolicyAnesthesia Services Professional, Commercial Reimbursement Policy

Policy CodePolicy C-09002

Change TypeMaterial revisions and clarifications

Effective DateNov 1, 2024

Next Review DateN/A

Key ActionReport anesthesia time in one-minute increments and convert minutes to units by dividing by 15 and rounding to the nearest tenth.

SourceLink

POLICY UPDATE CHANGES

Updated policy title from Professional Anesthesia Services and updated language for qualifying circumstances to always bundle; added modifiers G8, G9 and QS to the Related Coding section; updated modifier QZ reimbursement from 100% to 85%; added Physical Status Modifiers language.

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

Postoperative epidural or major nerve injections/catheter insertions by an anesthesiologist are eligible for separate reimbursement and are treated as one surgical service with reimbursement equal to 150% of the allowance for the code.

15 mintime unit increment

1-mintime reporting granularity

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Coverage Criteria for Anesthesia Reimbursement

inv-01: general billing and coding criteria

General reimbursement approach and billing requirements:

Anesthesia services must be reported using appropriate anesthesia CPT/HCPCS codes and, when applicable, physical status and who-performed (servicing) modifiers.

Anesthesia time must be reported in one-minute increments; anesthesia time starts with preparation of the member for administration of anesthesia and stops when the anesthesia provider is no longer in personal attendance.

To calculate time units, divide reported minutes by 15 and round to the nearest tenth; claims submitted with an indicator other than minutes may be rejected or denied.

The primary modifier field must identify who performed the anesthesia; failure to place the who-performed modifier in the primary modifier field may result in denial.

Combined reimbursement when both a physician and non-physician provide anesthesia is capped so that combined payment will not exceed 100% of the allowable for the physician-only service.

inv-02: procedural nuances

Multiple procedures, field avoidance, and qualifying circumstances:

When multiple surgical procedures occur, report only the anesthesia code for the most complex service; base units apply only to the primary procedure. If two separate anesthesia codes are reported, the lesser procedure will be denied (exception: add-on codes 01953, 01968, 01969).

Separate session allowance: If the anesthesia record documents a separate subsequent operative session with more than one hour separation from the initial anesthesia, the second service may be eligible for separate reimbursement.

For procedures requiring field avoidance around the head, neck or shoulder girdle, or requiring positioning other than supine or lithotomy, a minimum base value of 5 applies regardless of any lower assigned base value; unusual positioning is not eligible for additional reimbursement with modifier 22.

Qualifying circumstance codes (e.g., 99116, 99100, 99135, 99140) are considered always bundled and are not separately reimbursed.

inv-03: oral surgery

Oral surgery anesthesia rules:

CPT anesthesia codes 00170 and 00176 (anesthesia for intraoral procedures) are not eligible for reimbursement when reported with CDT procedure codes; likewise CDT anesthesia codes D9211 and D9248 are not eligible for separate reimbursement when reported with CPT procedure codes.

When an oral surgeon reports a CPT procedure and also provides the anesthesia service, the surgeon must append modifier 47; no additional reimbursement is paid for the anesthesia in that instance.

inv-04: global reimbursement inclusions and exceptions

Services included/excluded from global anesthesia reimbursement and separately payable services:

Global anesthesia reimbursement includes services integral to administration of anesthesia from pre-anesthesia evaluation through cessation of personal attendance; included items (not separately payable) include monitoring, placement of peripheral IVs, venipuncture/transfusion, inhalation treatments, echocardiography when part of monitoring, EEG, laryngoscopy/bronchoscopy, and placement of ET/NG tubes.

Anthem allows separate reimbursement for specified distinct procedures provided with anesthesia, including central venous pressure line insertion, Swan-Ganz catheter insertion, and intra-arterial lines; Transesophageal echocardiography (TEE) may be separately reimbursable only when performed as a distinct and independent procedure with the appropriate modifier (codes in 93312-93317).

Medications reported separately in the facility setting (including Propofol) are not eligible for separate reimbursement; facility drug charges are considered included in facility charges.

TEE when performed solely for monitoring purposes (e.g., CPT 93318) or for guidance of transcatheter interventions (e.g., CPT 93355) is considered incidental under NCCI edit logic and a bypass modifier will not override the edit.

inv-05: postoperative pain management

Postoperative pain management:

Postoperative pain management services performed by an anesthesiologist, such as injection or catheter insertion into the epidural space or a major nerve, are eligible for separate reimbursement; time units do not apply to these services.

The policy specifically references injection and nerve block code ranges 62320-62327 and 64400-64450 as eligible for postoperative pain management reimbursement.

When performed bilaterally, report the unilateral code once with modifier 50 using the applicable unilateral base value.

The postoperative management code is considered one surgical service and is eligible for reimbursement equal to 150% of the allowance for the code.

inv-06: Postoperative anesthesia pain management coverage criteria

Rules for reimbursement of postoperative pain management and modifier application

Epidural or major nerve injection or catheter insertion by an anesthesiologist for postoperative management is eligible for separate reimbursement as one surgical service at 150% of the allowance (applies to CPT range 62320-62327 and 64400-64450).

When postoperative pain management services are performed bilaterally, report the unilateral code once with modifier 50 using the applicable base value for the unilateral code.

CPT 01996 (daily hospital management of epidural/subarachnoid continuous drug administration) is reimbursable once per date of service following the surgery date; when CPT 01996 is billed with injection codes (e.g., 62320-62327), only the injection code is eligible for reimbursement and modifiers will not override this edit.

Modifier QZ reimbursement was updated from 100% to 85%; modifiers G8, G9, and QS were added to the Related Coding section as informational and physical status modifier language was added to the policy.

inv-07: Billing rules and related policy references

Billing and reimbursement rules, edits, and related policy references noted in policy history and related materials.

Section 7c is included in NCCI edits and modifier 59 must be appended for separate reimbursement when applicable.

Do not report CPT 01996 with a physical status modifier or qualifying circumstance codes; historical policy notes document prior edits and clarifications to coding and state-specific behaviors.

This policy references the related policy 'Global Surgical Package Professional' (C-09002) and contains history entries documenting changes to code lists, modifiers, and reimbursement logic; providers should review policy history and related materials for detailed context.

Codes, Modifiers, and Time Reporting

Anesthesia modifiers and physical statusModifierCovered

Physical status modifiers (ASA)	ASA physical status modifiers are assigned unit values for additional reimbursement when appended to base anesthesia codes.
Anesthesia primary modifiers	Modifiers identifying who performed the anesthesia must be billed in the primary modifier field to receive appropriate reimbursement; claims without the appropriate modifier will be denied.

special/crosswalk codesCPT

99100, 99116, 99135, 99140	Qualifying circumstance CPT codes (extreme age, hypothermia, controlled hypotension, emergency conditions) which the Health Plan considers always bundled when reported.
00170, 00176; D9211, D9248	CPT anesthesia for intraoral procedures (00170, 00176) and CDT oral surgery anesthesia codes (D9211, D9248) are mutually exclusive for separate reimbursement; when reported together the CPT or CDT anesthesia code will not be eligible for separate reimbursement as specified.

Postoperative pain management and daily management codesCPTCovered

62320-62327	Spinal injection codes referenced for postoperative pain management reimbursement; time units are not applicable; bilateral services reported once with modifier 50 using unilateral base value.
64400-64450	Major nerve block injection codes referenced for postoperative pain management reimbursement; time units are not applicable; bilateral services reported once with modifier 50 using unilateral base value.
01996	Daily hospital management of epidural/subarachnoid continuous drug administration; reimbursed once per date of service following the surgery date; when billed with injection codes (62320-62327) only the injection code is reimbursed and modifiers will not override this edit.

Modifiers with specified reimbursement behaviors or informational useModifierCovered

QZ	Anesthesia modifier with adjusted reimbursement (reimbursement updated from 100% to 85%).
G8	Modifier added to Related Coding section (informational).
G9	Modifier added to Related Coding section (informational).
QS	Modifier added to Related Coding section (informational; monitored anesthesia care).

Anesthesia coding notes from policy historyCPT

01953, 01968-01969	Add-on anesthesia codes referenced in policy history as separately reimbursed (historical note).
01996	Do not report with a physical status modifier or qualifying circumstances code (policy history restriction).

Time-to-units conversion

Conversion methodMinutes reported divided by 15 and rounded to the nearest tenth to determine time units for reimbursement.

Reporting granularityAnesthesia time must be reported in one-minute increments; start/stop times documented in the medical record.

Rejected formatsClaims submitted with an indicator other than minutes will be rejected or denied.

Time unit rounding policy (example NY/NH notes)

Market-specific rounding (New Hampshire)Rounds up to the next unit if there are 8 or more minutes.

Provider Billing Actions and Documentation Requirements

Billing Rule

Postoperative pain management separate reimbursement

Postoperative pain management services performed by an anesthesiologist (for example, an injection or catheter insertion into the epidural space or a major peripheral nerve) are eligible for separate reimbursement in addition to the primary anesthesia service. When such a distinct postoperative pain management procedure is performed, report the appropriate procedure code and append the modifier that indicates a distinct procedural service was performed.

Applicable codes/ranges noted in policy: 62320-62327, 64400-64450
When performed bilaterally, report the unilateral code once with modifier 50 using the unilateral base value

Denial Risk

Postoperative daily management reimbursement restriction

The Health Plan restricts reimbursement for daily hospital management of epidural or subarachnoid continuous drug administration (CPT 01996) for postoperative pain management as follows: CPT code 01996 is eligible for reimbursement once per date of service following the surgery date. If CPT 01996 is reported on the same date of service with an anesthetic injection or catheter procedure code in the 62320-62327 range (or other qualifying injection/catheter codes), only the injection/catheter procedure code will be eligible for reimbursement; the daily management code (01996) will be denied. Modifiers will not override these claim-editing rules.

Definitions and Operational Terms

Anesthesia time definition and reporting granularity

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

Reporting granularityMust be reported in one-minute increments with documented start and stop times in the medical record.

Interrupted careAnesthesia time can be counted in blocks if there is an interruption, provided only continuous anesthesia service time is counted.

Who-performed modifier placement requirement

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

Denial risk

Policy Summary

PayerEmpire Bluecross

PolicyAnesthesia Services Professional, Commercial Reimbursement Policy

Policy CodePolicy C-09002

Change TypeMaterial revisions and clarifications

Effective DateNov 1, 2024

Next Review DateN/A

Key ActionReport anesthesia time in one-minute increments and convert minutes to units by dividing by 15 and rounding to the nearest tenth.

SourceLink

On This Page

Documentation Required

Operational billing notes for postoperative pain management

When postoperative pain management procedures are provided in addition to the primary surgical/anesthesia service, report the separate procedure code for the injection or catheter insertion. Time units are not applicable to these postoperative pain management procedure codes. Reimbursement for a qualifying postoperative management procedure may be calculated at 150% of the allowance for the code when considered a single surgical service, per policy language.

Time units do not apply to postoperative pain management injection/catheter procedure codes
Policy language indicates the management code may be considered one surgical service and eligible for reimbursement equal to 150% of the allowance for the code (per policy)

Documentation Required

NCCI edits and modifier 59

Modifiers such as modifier 59 will not override NCCI or other edits that deny payment for a daily management code reported with an injection/catheter code. Ensure documentation supports a distinct procedural service when billing separate postoperative pain management codes, but be aware that the plan's edits may still prevent reimbursement for co-reported daily management (01996) when an injection/catheter code is billed on the same date of service.

Do not rely on modifier 59 or other modifiers to bypass edits that deny concurrent reimbursement of 01996 with injection/catheter codes
Maintain clear documentation that describes the clinical distinction and timing of services — though edits may still control final reimbursement