Modifiedharvard pilgrim health carePolicy N/A

Anesthesia Pp

Defines Point32Health (Harvard Pilgrim and Tufts Health Plan) reimbursement, billing, unit calculation, allowed and non-reimbursed anesthesia services, modifier and documentation requirements, and product-specific rules for anesthesia, moderate sedation, monitored anesthesia care, and related pain management services for contracted providers.

Policy Summary

Payerharvard pilgrim health care

PolicyAnesthesia Pp

Policy CodePolicy N/A

Change TypeTemplate move; all lines of business included

Effective Date

Next Review Date

Key ActionInclude anesthesia start and stop times on documentation; teaching anesthesiologist must document presence during all critical/key portions and immediate availability for reimbursement of teaching services.

SourceLink

POLICY UPDATE CHANGES

Policy moved to new template; includes all lines of business.

1Primary anesthesia service billed when multiple procedures

10+Example covered anesthesia and modifier codes listed

1Policy template move date

Policy Summary

Point32Health (Harvard Pilgrim Health Care and Tufts Health Plan) reimburses contracted anesthesia providers for general, regional, or local anesthesia and related supportive services, subject to member benefits, eligibility, authorization rules, and provider contracts. Payment is based on American Society of Anesthesiologists (ASA) codes and the Anesthesia Unit System and uses ASA base values plus time units when applicable. Product-specific unit conversion and modifier payment rules apply (see time unit conversion and modifier sections).

Reimbursable and Non-Reimbursable Services

Reimbursable Anesthesia Services

Covered when ALL of the following are met:

ALL of the following

Anesthesia services are billed using American Society of Anesthesiologists (ASA) anesthesia codes and the Anesthesia Unit System.
The service represents general, regional, or local anesthesia or monitored anesthesia care associated with a covered procedure or service.
Documentation supports the start and stop times for anesthesia and any additional time units billed (documentation must be in the medical record).
Minutes will be converted into time units during claims processing per applicable product-specific rules.
Only the primary anesthesia service with the highest unit value is billed when multiple surgical procedures are performed during a single anesthetic administration.
Base values are consistent with ASA definitions and general anesthesia reimbursement is based on the sum of allowable base and time units.
Medically directed services, teaching anesthesiologist services, obstetrical anesthesia, monitored anesthesia care, and specified invasive monitoring procedures (e.g., central venous pressure monitoring, Swan-Ganz catheter, transesophageal echocardiography when performed with general anesthesia) are supported when documentation and billing meet CMS and policy definitions.

Outpatient Pain Management Reimbursable Items

Covered when ALL of the following are met:

ALL of the following

Outpatient regional blocks, therapeutic injections, and trigger point injections are performed by an anesthesiologist and billed using appropriate CPT/ASA codes.
Fluoroscopic guidance and localization are documented and billed when appropriate for the procedure.
Outpatient evaluation and management services billed in conjunction with anesthesia-related outpatient pain management are supported when medically necessary and documented.
When anesthesia providers perform regional blocks or therapeutic injections in an outpatient setting, standard surgical rate methodology applies (base plus time as appropriate).

Non-Reimbursable / Included Activities

The following activities are considered part of the base anesthesia service and are included in the base value; they are not reimbursed separately:

ANY of the following

All usual pre- and post-operative services, including routine evaluation and management services.
Induction of anesthesia during the procedure and usual monitoring procedures associated with the complexity of the service.
Incidental administration of parenteral fluids and/or blood products.
Ventilation management related to the surgical anesthesia and usual intraoperative respiratory management.
Insertion of a catheter on the same day that epidural anesthesia was delivered during surgery (included in the base value).

Product-specific Restriction

Product-specific restriction and modifier payment rules:

ALL of the following

Tufts Health Plan only: ASA code 00811 billed with modifier PT is not reimbursed unless a CPT surgical code has been billed for the same date of service by any provider.
Submit one anesthesia modifier per anesthesia service claim line; physical status modifiers (P1–P6) are required and should be reported in the secondary position when applicable.
Modifier payment rules for Harvard Pilgrim Health Care Commercial and Tufts products: AA reimbursed at 100% of allowable when applicable; AD (medical supervision >4 concurrent) requires documentation and is reimbursed per policy rules; QK/QY/QX/QS/QZ reimbursement and percentage splits follow the payer-specific guidance in this policy and must be billed per CMS definitions.
Advanced Practice Provider (APP) and CRNA modifiers (QX/QZ/QY) must be reported consistent with medical direction or supervision documentation; reimbursement percentages depend on the modifier and payer as outlined in the policy.

Codes and Modifiers

ASA/Anesthesia base and time methodology (allowed)mixedCovered

00811	Anesthesia for procedures on the upper abdomen, lower abdomen, or other — (product-specific restriction with modifier PT noted)
01960	Anesthesia for vaginal delivery only
01961	Anesthesia for Cesarean delivery only
01967	Neuraxial labor analgesia/anesthesia for planned vaginal delivery
01968	Anesthesia for cesarean delivery following neuraxial labor/anesthesia (list separately in addition to code for primary procedure performed)
01969	Anesthesia for cesarean hysterectomy following neuraxial labor analgesia/anesthesia
G0500	Moderate sedation services provided by the same physician/QHP performing GI endoscopic service that sedation supports
99151	Moderate sedation services (provider not performing the diagnostic/therapeutic service) — time-based codes included in policy references
99152	Moderate sedation services provided by same physician/QHP performing the diagnostic or therapeutic service (note billing interactions described in policy)

Modifiers and payment rulesModifier

AA	Anesthesia services performed personally by anesthesiologist; reimbursed at 100%
AD	Medical supervision for more than four concurrent anesthesia; documentation required; reimbursement rules vary by product
G8	MAC for deep/complex procedures; modifier use will not impact reimbursement
G9	MAC for severe cardiopulmonary condition; modifier use will not impact reimbursement
GC	Service performed in part by resident under direction of teaching physician; reimbursed at 100% when billed by teaching physician
P1	Physical status modifier (P1-P6 required in secondary position)
P2	Physical status modifier (P1-P6 required in secondary position)
P3	Physical status modifier (P1-P6 required in secondary position)
P4	Physical status modifier (P1-P6 required in secondary position)
P5	Physical status modifier (P1-P6 required in secondary position)

1–10 of 16

1/2

Not reimbursed / Included-in-base (examples listed)mixedNot Covered

CPT codes designated by the ASA as not normally requiring anesthesia (listed as not reimbursed separately)

Payment is governed by ASA base values and the anesthesia time methodology: reimbursement is the sum of allowable base units and time units derived from documented anesthesia start and stop times. During claims processing minutes are converted into time units per product-specific rules (for example, Tufts Health Commercial converts each 15-minute interval to 1 time unit with 8–14 minutes rounding up and 1–7 minutes rounding down; Harvard Pilgrim Commercial and Tufts Senior products convert each 15-minute interval to 1 unit with rounding to the nearest tenth; Tufts Public Plans allow fractions >= 5 minutes up to 15 minutes).

When multiple surgical procedures are billed during a single anesthetic, only the primary anesthesia service with the highest unit value is reimbursed. Product-specific coding interactions and restrictions apply (for example, Tufts Health Plan will not reimburse ASA code 00811 when billed with modifier PT unless a CPT surgery code has been billed for the same date of service). The policy also describes billing interactions for moderate sedation codes (e.g., G0500, 99151–99152) and modifier payment rules (AA, AD, QK, QX/QY, GC, P1–P6, etc.).

Billing & Documentation Requirements

Documentation Required

Anesthesia start/stop times and teaching presence documentation

Include anesthesia start and stop times on documentation; teaching anesthesiologist must document presence during all critical/key portions and immediate availability for reimbursement of teaching services.

Anesthesia start and stop times
Teaching anesthesiologist presence during all critical/key portions
Teaching anesthesiologist immediate availability

Billing Rule

Primary anesthesia service selection

When multiple surgical procedures are billed during a single anesthetic administration, bill only the primary anesthesia service with the highest unit value.

Billing Rule

Modifier reporting

Submit one anesthesia modifier per anesthesia service claim line. Required modifiers include AA, GC, and physical status modifiers P1–P6. Physical status modifiers (P1–P6) must be reported in the secondary position. Follow GC/AA ordering as specified for teaching physician billing.

Required modifiers: AA, GC, P1, P2, P3, P4, P5, P6
Physical status modifiers P1–P6 reported in secondary position
One anesthesia modifier per claim line

Billing Rule

Tufts 00811 PT restriction

Product-specific restriction: Tufts Health Plan will not reimburse ASA code 00811 with modifier PT unless a CPT surgical code has been billed for the same date of service by any provider.

00811 (when billed with modifier PT)

Denial Risk

Non-covered included activities

Claims may be denied or not reimbursed for services considered part of the anesthesia base. Common non-reimbursable items include routine pre- and post-operative evaluation and management services, induction of anesthesia during the procedure, usual monitoring procedures, and insertion of a catheter on the same day epidural anesthesia was delivered. Do not bill these items separately to avoid denial.

Routine pre- and post-operative E/M services
Induction of anesthesia during the procedure
Routine monitoring procedures
Insertion of a catheter on the same day as epidural anesthesia

Documentation Required

AD modifier documentation

When billing modifier AD (medical supervision of more than four concurrent anesthetics), documentation is required. Harvard Pilgrim: documentation required; reimbursed equal to three base units plus one additional unit if the physician was present for intubation. Tufts Health Plan: reimbursed at 50% of the fee schedule/allowable rate.

Documentation of medical supervision >4 concurrent required
Harvard Pilgrim reimbursement: three base units (plus one additional unit if present for intubation) with documentation
Tufts reimbursement: 50% of fee schedule/allowable rate

Time Unit Conversion & Calculation

Time Units and Calculating Units

Documentation and conversion rules for anesthesia time units:

ALL of the following

Documentation must include anesthesia start and stop times
During claims processing minutes will be converted into time units and reimbursement will be based on the sum of the allowable base and time units
Maximum units may be applied to anesthesia services
Product-specific conversion rules
- Tufts Health Commercial: Each 15-minute interval is converted to one time unit, rounding up to the next unit for 8-14 minutes and rounding down for 1-7 minutes
- Harvard Pilgrim Commercial and Tufts Senior: Each 15-minute interval is converted to one time unit, rounding to the nearest tenth of a unit (one decimal place)
- Tufts Health Public Plans: Each 15-minute interval is converted to one time unit, or a fraction of 15 minutes equal to or exceeding five minutes, up to 15 minutes

Anesthesia Time Unit Conversion Thresholds

Tufts Health Commercial conversion ruleEach 15-minute interval = 1 time unit; 8-14 minutes round up, 1-7 minutes round down

Harvard Pilgrim Commercial & Tufts Senior conversion ruleEach 15-minute interval = 1 time unit; rounding to the nearest tenth of a unit

Tufts Public Plans conversion ruleEach 15-minute interval = 1 time unit; fractions >=5 minutes up to 15 minutes allowed

OpenPayer

Anesthesia Pp

Policy Summary

Reimbursable and Non-Reimbursable Services

Codes and Modifiers

Billing & Documentation Requirements

Time Unit Conversion & Calculation

Key Terms

Policy Changes & Publication History