CurrentHighmark Blue Cross Blue Shield WnyPolicy G-07018

Professional Anesthesia Services PDF

Defines Highmark BCBS WNY reimbursement rules for professional anesthesia services for MMC, HARP, CHPlus, and Essential Plan members including time reporting, modifiers, multi-procedure payment, obstetrical neuraxial epidural limits, reimbursable adjunct services, and nonreimbursable items.

Policy Summary

PayerHighmark Blue Cross Blue Shield Wny

PolicyProfessional Anesthesia Services PDF

Policy CodePolicy G-07018

Change TypeAdministrative/template updates (no material clinical changes)

Effective DateNov 6, 2020

Next Review Date

Key ActionProviders must report anesthesia services in minutes and document start/stop times; claims without minute reporting or appropriate anesthesia modifiers may be denied.

SourceLink

POLICY UPDATE CHANGES

06/13/2023 Review approved: policy template updated.

11/06/2020 Review approved and effective: minor administrative updates; added anesthesia modifier grid.

300Obstetrical epidural time limit

15Anesthesia time unit (minutes)

G-07018Policy Number

Policy overview

Policy Number: G-07018; Status: CURRENT. This Highmark BCBS WNY reimbursement policy governs professional anesthesia services for Medicaid Managed Care (MMC), Health and Recovery Plan (HARP), Child Health Plus (CHPlus), and Essential Plan members and aligns with CMS guidelines. (See policy identifiers and program scope.)

Highmark BCBS reimburses professional anesthesia using a CMS-aligned methodology: reimbursement is calculated from base units (procedure relative value), plus time units reported in minutes using 15-minute increments as the anesthesia time unit, multiplied by a conversion factor that varies by locality. Providers must document anesthesia start and stop times and report time in minutes; claims using other time indicators may be rejected or denied.

Anesthesia modifiers that identify who performed the service must be appended (billed in the primary modifier field); claims without the appropriate modifier will be denied. Additional or reduced payment for modifiers follows state requirements or, if none, defaults to CMS guidelines. For multiple procedures, reimbursement is based on the procedure with the highest base unit value plus the overall anesthesia time. Obstetrical neuraxial epidural analgesia is reimbursed up to 300 minutes (providers may submit documentation for disputes regarding time beyond 300 minutes).

Policy metadata and headline thresholds

Policy NumberG-07018

Effective Date2020-11-06

Last Review2023-06-13

Next Review

Obstetrical epidural time limit300 minutes

Anesthesia time unit15 minutes

Reimbursement criteria

General Reimbursement Criteria

Anesthesia professional services are reimbursed when billed per policy and documented:

ALL of the following

Services rendered by professional providers for covered members (MMC, HARP, CHPlus, Essential Plan) unless provider/state/federal/CMS contracts indicate otherwise
Reimbursement based on reimbursement formula for allowance and time increments in accordance with CMS guidelines
Providers must report anesthesia services in minutes; start and stop times must be documented in the member's medical record
Anesthesia time starts with preparation of the member for administration of anesthesia and stops when the anesthesia provider is no longer in personal and continuous attendance
Anesthesia modifiers identifying who performed the service must be billed in the primary modifier field
Additional or reduced payment for modifiers is based on state requirements; if no state requirement, default to CMS guidelines
Claims submitted for anesthesiology services without the appropriate modifier will be denied

Multiple Procedures

Payment when multiple procedures occur during same anesthesia encounter:

Reimbursement based on the anesthesia procedure with the highest base unit value and the overall time of all anesthesia procedures

Obstetrical Neuraxial Epidural Analgesia

Coverage for epidural analgesia in labor and delivery:

ALL of the following

Reimbursement basis
- Delivering physician: based on a flat rate or fee schedule using the surgical CPT pain management codes for epidural analgesia
- Qualified provider other than delivering physician: based on the allowance calculation and inclusion of catheter insertion and anesthesia administration

Separately Reimbursable Services Provided with Anesthesia

The following services may be reimbursed separately from anesthesia:

ANY of the following

Swan-Ganz catheter insertion
Central venous pressure line insertion
Intra-arterial lines
Emergency intubation (must be provided in conjunction with the anesthesia procedure)
Critical care visits

Nonreimbursable Anesthesia Services

Highmark BCBS does not reimburse the following:

ANY of the following

Use of patient status modifiers or qualifying circumstances codes denoting additional complexity levels
Anesthesia consultations on the same date as surgery or the day prior to surgery if part of the preoperative assessment
Anesthesia services performed for noncovered procedures, including services considered not medically necessary, experimental, and/or investigational
Anesthesia services by the provider performing the basic procedure, except for a delivering physician providing continuous epidural analgesia
Local anesthesia considered incidental to the surgical procedure

Code lists and modifiers

Billing and coding systems requiredmixed

No codes listed

Anesthesia Modifiers (policy references modifier grid attachment)Modifier

No codes listed

Billing, documentation, and denial risk

Billing Rule

Report anesthesia time in minutes

Providers must report anesthesia services in minutes. Claims submitted with an indicator other than minutes may be rejected or denied. Start and stop times must be documented in the member's medical record.

Report in minutes; start/stop times documented; claims with other indicators may be rejected or denied.

Billing Rule

Append appropriate anesthesia modifiers

Anesthesia modifiers identifying who performed the service must be billed in the primary modifier field to receive appropriate reimbursement. Claims submitted for anesthesiology services without the appropriate modifier will be denied.

Documentation Required

Document anesthesia start and stop times and attendance

Start and stop times must be documented. Anesthesia time starts with the preparation of the member for administration of anesthesia and stops when the anesthesia provider is no longer in personal and continuous attendance. Document provider attendance and exact start/stop times in the medical record.

Documentation Required

Submit documentation for epidural time >300 minutes

For neuraxial epidural analgesia in labor and delivery, reimbursement is allowed for up to 300 minutes. Providers must submit additional documentation upon dispute for consideration of reimbursement of time in excess of 300 minutes.

Key definitions

AnesthesiaRefers to the drugs or substances that cause a loss of consciousness or sensitivity to pain.

Base unitThe relative value unit associated with each anesthesia procedure code as assigned by CMS.

Time unitAn increment of 15 minutes where each 15-minute increment constitutes one time unit.

Conversion factorA geographic-specific amount that varies by the locality where the anesthesia is administered.

Policy history

11/06/2020revised

Review approved and effective: minor administrative updates; added anesthesia modifier grid.

06/13/2023revisedLatest

Review approved: policy template updated.