harvard pilgrim health care Anesthesia Coverage

Policy scope and summary

This policy defines anesthesia as the loss of feeling or sensation from medications or gases and distinguishes general anesthesia (loss of consciousness) from local or regional anesthesia (numbs a specific area). It applies to contracted anesthesia providers and addresses reimbursement, billing, and documentation requirements for general, regional, monitored anesthesia care, obstetrical, pain management, and moderate sedation services.

Payment is determined by member benefits, eligibility, medical necessity review where applicable, and the provider contract. Harvard Pilgrim reserves the right to amend this payment policy, and CPT and HCPCS codes are updated annually and should be used as current.

Definitions and obstetrical time caps

Anesthesia timeStarts when the anesthesiologist begins to prepare the patient for induction and ends when the patient can safely be placed under post-operative supervision.

Anesthesia unitsInclude ASA basic/base values (Harvard Pilgrim automatically assigns base units) plus time units (15 minutes or a pro-rated portion based on actual minutes submitted).

Vaginal delivery neuraxial capCapped at a total of 225 minutes (15 time units).

Cesarean delivery neuraxial capCapped at a total of 270 minutes (18 time units).

Reimbursement criteria and exclusions

General reimbursement criteria

Covered when ALL of the following are met:

ALL of the following

Provider is a contracted anesthesia provider (anesthesiologist, CRNA, or other qualified individual).
Services are reported using American Society of Anesthesiologists (ASA) anesthesia codes (00100–01999) and the Anesthesia Unit System.
When multiple surgical procedures are performed during a single anesthetic administration, only the procedure with the highest anesthesia unit value is reimbursed (single-procedure highest unit rule).
Reimbursement is based on the sum of allowable base units and time units; Harvard Pilgrim automatically assigns base units.

Codes and modifiers

ASA anesthesia codes (primary general anesthesia service)CPTCovered

00100-01999

ASA anesthesia codes used to report primary general anesthesia service

Anesthesia-related CPTs reimbursed with general anesthesia serviceCPTCovered

36620	Arterial catheterization or cannulation for sampling, monitoring or transfusion, percutaneous (reimbursed with general anesthesia service)
93503	Insertion and placement of flow directed catheter (e.g., Swan-Ganz) for monitoring (reimbursed with general anesthesia service)

Anesthetic injection codes - separate and distinct (may be reimbursed with ASA when modifier applied)CPTCovered

62320-62323	Injection of diagnostic/therapeutic substance not via an indwelling catheter (may be reimbursed with ASA when separate and distinct and reported with appropriate modifier)
64413	Injection(s) of anesthetic agent(s) (reimbursed with ASA codes when separate and distinct and reported with appropriate modifier)
64415	Injection(s) of anesthetic agent(s)
64416-64425	Injection(s) of anesthetic agent(s)
64445-64451	Injection(s) of anesthetic agent(s)
64454-64455	Injection(s) of anesthetic agent(s)

Moderate (conscious) sedation codes - guidanceCPT|HCPCSCovered

G0500	Moderate sedation for GI endoscopic service; bill with CPT 43200-45398, HCPCS G0105 and G0121
99151-99152	Moderate sedation by same physician/qualified professional requiring independent trained observer (99152 not reimbursed when billed with CPT 43200-45398, HCPCS G0105 and G0121)
99153	Moderate sedation additional time; use in addition to G0500 or 99151-99152
99157	Moderate sedation by physician other than the performing physician; each additional 15 minutes; use in addition to 99155-99156

Obstetrical anesthesia codesCPTCovered

01960	Anesthesia for vaginal delivery only (bill when no neuraxial/anesthesia involved with vaginal delivery; not reimbursed with 01967)
01961	Anesthesia for Cesarean delivery only (use for planned cesarean; not reimbursed with 01968)
01967	Neuraxial labor analgesia/anesthesia for planned vaginal delivery (time unit cap limits apply)
01968	Anesthesia for cesarean delivery following neuraxial labor/anesthesia (must be reported in addition to 01967; not reimbursed when billed alone)
01969	Anesthesia for cesarean hysterectomy following neuraxial labor analgesia/anesthesia (must be reported in addition to 01967; not reimbursed when billed alone)

Pain management daily hospital management codeCPTCovered

01996

Daily hospital management of epidural or subarachnoid continuous drug administration – bill for subsequent daily pain management services (inappropriate on same day catheter used to deliver anesthesia)

Catheter/injection codes for pain managementCPTCovered

62324-62327

Injection including catheter placement, continuous infusion or intermittent bolus for diagnostic/therapeutic substances; bill for catheter insertion for pain management when not used as anesthetic; reimbursed with ASA codes when separate and distinct and reported with modifier

Outpatient E/M for pain managementCPTCovered

99211-99215

Outpatient evaluation and management codes; bill for outpatient pain management services

Non-reimbursed / Not covered codes and situationsCPT|HCPCSNot Covered

99051	Services provided in the office during regularly scheduled evening/weekend/holiday hours – Not reimbursed
99053	Services provided between 10:00 p.m. - 8:00 a.m. at a 24-hour facility in addition to basic service – Not reimbursed
99060	Services provided on an emergency basis out of office disrupting scheduled visits in addition to basic service – Not reimbursed
99100, 99116, 99135, 99140	Qualifying circumstances for anesthesia – Not reimbursed
00300, 00400, 00600, 01937-01942, 01991-01992, 99152-99153, 99156-99157	Anesthesia and moderate sedation codes that will not be reimbursed when billed with pain management services and billed without a surgical code for members age 18+ (see policy)

Modifier requirementsModifier

AA	Anesthesia services performed personally by anesthesiologist; allows 100% of fee schedule/allowable rate. Bill with CPT/ASA code.
AD	Medical supervision for >4 concurrent anesthesia procedures (documentation required); reimbursed at a rate equal to three base units plus one additional unit if present for intubation
G8	Monitored anesthesia care (MAC) for deep, complex, complicated or markedly invasive procedures
G9	MAC for patient with history of severe cardiopulmonary condition
GC	Services performed in part by a resident under direction of teaching physician; reimbursable at 100% when billed by teaching anesthesiologist (AA in first position, GC in second)
P1-P6	Physical status modifiers required and reported in secondary modifier position; do not impact reimbursement
QS	Monitored anesthesia care provided by an anesthesiologist
QZ	CRNA performed services without medical direction
QY	Anesthesiologist medically directed one CRNA; allows 50% of fee schedule/allowable rate
QK	Medical direction of 2-4 concurrent anesthetic procedures; allows 50% of fee schedule/allowable rate

1–10 of 11

1/2

Billing, submission & documentation requirements

Billing Rule

Report total anesthesia time in minutes

Must bill total anesthesia time in minutes; do not report time units. For paper claims, enter elapsed minutes in Block 24G. For electronic claims, use the minute field: loop 2400, segment SV1, data element SV103 with MJ qualifier. Use three digits to record minutes (e.g., 33 minutes = 033).

Paper: Block 24G — report total minutes (elapsed time) in narrative
Electronic: Loop 2400, segment SV1, data element SV103 with MJ qualifier; use three-digit minutes (e.g., 033)

Denial Risk

Anesthesia with pain management billed without surgical code for adults

Anesthesia and moderate sedation codes listed will not be reimbursed when billed with pain management services and billed without a surgical CPT (10021-69990) for members age 18 or older. Affected codes include 00300, 00400, 00600, 01937-01942, 01991-01992, 99152-99153, and 99156-99157. This exclusion was published 05/01/19 and effective 07/01/19.

Non-reimbursable situations

Certain qualifying circumstance codes are not reimbursed, including 99051, 99053, 99060, 99100, 99116, 99135, and 99140. The policy also lists other anesthesia and moderate sedation codes that will not be reimbursed when billed with pain management services without a surgical CPT for members age 18 or older (for example 00300, 00400, 00600, 01937-01942, 01991-01992, 99152-99153, 99156-99157).

Key definitions

Definitions and neuraxial time caps

Anesthesia timeStarts when the anesthesiologist begins to prepare the patient for induction and ends when the patient can safely be placed under post-operative supervision.

Anesthesia unitsInclude ASA basic/base values (Harvard Pilgrim automatically assigns base units) and time units of 15 minutes or a pro-rated portion based on actual minutes submitted.

Vaginal delivery neuraxial capTime units for neuraxial/epidural labor for vaginal delivery are capped at 225 minutes (15 time units).

Cesarean delivery neuraxial capTime units for neuraxial/epidural labor for cesarean delivery are capped at 270 minutes (18 time units).

Policy changes & publication history

05/01/19 (effective 07/01/19)material_change

Anesthesia and moderate sedation will no longer be reimbursed when billed with pain management services without a surgical code for members age 18 or older (effective 07/01/19).

12/31/24administrative_edit

Annual review; administrative edit recorded in publication history.

12/01/25annual_reviewLatest

Annual review; no changes.