Payment calculation and directed vs. personally performed rules
Payment calculation and rules for personally performed versus directed anesthesia services, including modifiers, concurrent cases, required documentation, and reimbursement percentages.
Anesthesia payment is based on base units plus time units (one time unit per 15 minutes of anesthesia time). Report actual anesthesia time in minutes on the claim; the Plan will convert minutes to time units by dividing total minutes by 15 and rounding to one decimal place (e.g., 48 minutes = 3.2 time units). For moderate (conscious) sedation report units, not minutes.
When a physician personally performs the entire anesthesia service, payment is determined by the base unit for the anesthesia code plus the calculated time units multiplied by the conversion factor.
Payment for personally performed anesthesia applies when the physician: (a) personally performed the entire anesthesia service alone; (b) is a teaching physician involved with one or two concurrent resident cases or in one resident case concurrent to another case paid under medical direction rules; (c) is continuously involved in a single case involving a student nurse anesthetist; (d) is involved in a single case with a CRNA or an anesthesia assistant (AA) where payment can follow medical direction rules; or (e) and a CRNA/AA are both involved in one anesthesia case and documentation supports the medical necessity of full fees for both providers. Documentation must be submitted by both providers when seeking full payment for both.
For directed (medically directed) anesthesia services: direction occurs when a physician directs two, three, or four concurrent cases and performs required direction activities. The physician-directed service reimbursement is 50% of the allowance that would be recognized had the physician personally performed the service. The qualified individual's service (CRNA/AA) is likewise reimbursed at 50% of the physician allowance.
Required physician activities to meet direction criteria (physician must document these in the medical record): (1) Perform a pre‑anesthetic examination and evaluation; (2) Prescribe the anesthesia plan; (3) Personally participate in the most demanding procedures of the anesthesia plan, including induction and emergence when applicable; (4) Ensure procedures not personally performed are performed by a qualified anesthetist; (5) Monitor the course of anesthesia administration at frequent intervals; (6) Remain physically present and available for immediate diagnosis and treatment of emergencies; and (7) Provide indicated post‑anesthesia care.
Concurrent direction rules: the physician may direct two, three, or four concurrent procedures involving qualified individuals (CRNAs, AAs, interns, residents, student nurse anesthetists, or combinations). Direction rules apply to student nurse anesthetist cases as described (e.g., two concurrent cases each involving a student nurse anesthetist).
When a physician directs concurrent anesthesia procedures, the physician ordinarily should not be performing additional unrelated services for other patients. Brief, short‑duration activities in the immediate area (e.g., addressing a short emergency, administering an epidural to ease labor pain, periodic obstetrical monitoring, receiving patients entering the operating suite, checking/discharging recovery room patients, or handling scheduling) do not ordinarily diminish direction status.
If the physician leaves the immediate area for more than short durations, devotes extensive time to an emergency, or is otherwise unavailable to respond to the immediate needs of the surgical patients, the physician's services are considered supervisory and reimbursement for direction cannot be made.
When the anesthesiologist is involved in performing more than four procedures concurrently or is performing other services while directing concurrent procedures, only three base units per procedure may be allowed. An additional time unit may be recognized if the physician documents personal presence at induction.
Group practice coordination: one physician member may perform the pre‑anesthesia examination and evaluation while another member fulfills other direction criteria (including post‑anesthesia care). The medical record must identify the physicians and indicate the services each performed.
Modifiers and coding: providers must append appropriate anesthesia modifiers to denote personal performance, direction, or supervision. Common modifiers include: AA = personally performed by anesthesiologist; QK = medical direction of 2–4 concurrent CRNAs; QY = medical direction of one CRNA; QX = CRNA service with medical direction by a physician; QZ = CRNA service without medical direction by a physician; AD = medical supervision by a physician (more than 4 concurrent anesthesia procedures); G8/G9/QS as applicable for monitored anesthesia care. The QS modifier is informational only. Providers must report actual anesthesia time on the claim line.
Documentation requirements: for directed services the physician must document pre‑anesthetic exam and evaluation, presence during the most demanding portions (including induction/emergence when applicable), provision of indicated post‑anesthesia care, and that they monitored the case at frequent intervals. When seeking full payment for both physician and CRNA services, both providers must submit documentation supporting medical necessity.
Payment interaction examples for obstetrical epidural/cesarean care: when a physician personally performs both labor epidural (01967) and cesarean (01968), each line is reimbursed at 100% (AA). If the physician personally performs the labor epidural (AA) and medically directs a CRNA during the cesarean, 01967 (AA) is reimbursed at 100% and 01968 with modifier QK is reimbursed at 50% (BU + TU x conversion factor x 50%).
Special case — more than four concurrent procedures: if directing more than four procedures concurrently, only three base units per procedure may be allowed; an additional time unit may be considered only with documentation of presence at induction.