This policy (RP-033) defines Highmark BlueShield NENY reimbursement for anesthesia services and applies to professional and facility claims submitted on UB and CMS-1500 forms for the listed markets (including PA, WV, DE, NY). It establishes which anesthesia types qualify for payment, the calculation used to determine professional anesthesia reimbursement, required claim reporting, applicable provider roles, and special situations such as dental and obstetric anesthesia, monitoring, elastomeric pump supplies, and cancelled/aborted procedures.
Qualifying anesthesia services include inhalation, spinal, regional, epidural (caudal), field block, nerve block, intravenous, rectal, and conscious (moderate) sedation. Local infiltration (A9270) is explicitly not covered as a separate reimbursable anesthesia service. Anesthesia for diagnostic/therapeutic nerve blocks (CPT 01991, 01992) is reimbursable when performed by a different provider (noted codes listed in policy).
Payment is calculated using the standard anesthesia formula: (base units + time units + eligible modifying units) × conversion factor. The basic unit value when multiple procedures occur is the highest-valued procedure; basic units for additional procedures are not reimbursed. Anesthesia time begins when the anesthesiologist or CRNA first attends the patient to create the anesthetic state and ends when no longer in personal attendance.
Providers must report actual anesthesia time on the claim as minutes in the "days or units" block; the Plan converts reported minutes to time units where 1 time unit = 15 minutes (total minutes ÷ 15, rounded to one decimal place). For moderate (conscious) sedation, report units (not minutes) per policy instructions.
Modifier reporting is required to indicate provider role and level of service. Use anesthesia modifiers such as AA, AD, G8, G9, QK, QS, QX, QZ (QS informational only) to denote personally performed, medical supervision, monitored anesthesia care, medical direction, and CRNA reporting. The Plan does not separately reimburse modifying codes 99100, 99116, 99135, or 99140 (these represent special circumstances and may be subject to flat-fee rules or regional product exceptions).
Payment distinctions by provider role: when a physician personally performs the entire anesthesia service (or meets specified teaching/continuous-involvement criteria), payment equals base units plus one time unit per 15 minutes. When a physician directs anesthesia for 2–4 concurrent cases and meets documentation/participation criteria, physician payment is 50% of the allowance for the physician-alone service. When one CRNA service is supervised and both physician and CRNA bill, payment for each service is typically 50% of the allowance and modifier QX should be appended where required.
Monitoring services performed as part of anesthesia are considered included in the anesthesia allowance and are not separately reimbursable when billed with anesthesia; if monitoring services are independently performed they may be billed separately only with modifier 59 and supporting documentation in the medical record. If monitoring and anesthesia charges are itemized on the same claim, the Plan will combine charges and reimburse only the anesthesia allowance.
Special case guidance: dental anesthesia must use CDT codes (initial 15 minutes: D9222, D9239; subsequent 15-minute increments: D9223, D9243) billed at one unit per 15 minutes on separate claim lines. Obstetric add-on anesthesia codes (e.g., labor/delivery codes listed in policy) are add-on only and must be billed with the primary service on the same date of delivery or they will be rejected. When screening colonoscopy converts to diagnostic, report anesthesia with CPT 00811 and append modifier PT (screening → diagnostic conversion); screening-only anesthesia uses 00812.
Elastomeric infusion pumps and associated catheters (HCPCS A4305, A4306) must be FDA-approved. Catheter insertion/removal is included in the surgical allowance and is not separately reimbursable; pump supplies are typically facility expenses, and physician reporting of pumps is adjudicated per the member’s benefits.
Claims for cancelled or aborted procedures: if surgery is cancelled due to the anesthesiologist’s preoperative appraisal, reimbursement may be considered as a consultation according to member benefits; if surgery is aborted after induction, reimbursement is 3 basic units plus time units (converted per the standard anesthesia formula).
Documentation requirements: providers must document anesthesia time on the anesthesia record and meet the Plan’s documentation standards when billing directed or personally performed services (pre-anesthetic exam, participation in the most demanding portions of care, monitoring activity, and post-anesthesia care). When both physician and CRNA seek payment for the same case, supporting documentation from both practitioners is required to justify payment of full fees.
Operational scope: this policy governs professional and facility reimbursement where applicable by contract and is intended for anesthesiologists, CRNAs, facilities, and billing staff submitting UB/CMS-1500 claims. Regional and product-specific exceptions (for example, certain MA product rules or West Virginia applicability notes) are noted within the policy; always check the policy header and related product guidance for market-specific rules.
Related references and cross-references: see policy RP-033 for the full code lists, modifier definitions, and related policies (RP-025, RP-009/RP-00g, RP-035, RP-041) and Medicare Advantage medical policy N-118 where applicable for additional direction on qualified anesthetist billing and medical direction scenarios.