CurrentHighmark DelawarePolicy RP-033

RP-033 Anesthesia Services

Reimbursement policy for anesthesia services (commercial and Medicare Advantage) including which anesthesia types qualify, time/unit calculation, modifiers, monitoring/related services billing rules, elastomeric pump supplies, position/physical status units, dental and obstetrical anesthesia guidance, and codes not separately reimbursed.

Policy Summary

PayerHighmark Delaware

PolicyRP-033 Anesthesia Services

Policy CodePolicy RP-033

Change TypeClarifications, additions and administrative review

Effective DateMar 12, 2018

Next Review DateN/A

Key ActionReport actual anesthesia time as minutes in the 'days or units' block so the Plan can convert minutes to time units; report units (not minutes) for moderate sedation.

SourceLink

POLICY UPDATE CHANGES

Clarified section for Screening Colonoscopy code 00812 (April 2025 bulletin entry).

Administrative policy review with no changes in policy direction (February 2024).

Added Dental, Labor and Delivery sections (August and October 2019 entries).

Added note the plan will not separately reimburse codes 99100, 99116, 99135, 99140 (December 2021).

Removed CPT 94770, 94750 and removed MA Medical Policy N-118 (June 2022).

Issue Date April 28, 2025 bulletin indicating clarifications and additions (page references elsewhere).

Added NY region applicability with note for NY under Modifying Units section (October 2021).

Added Dental, Labor and Delivery guidance to policy (08/2019).

Added Medicare Advantage note under Modifying Units (07/2021).

Added Dental, Labor and Delivery (08/2019).

Added additional verbiage related to Dental, Labor and Delivery (10/2019).

10+Key anesthesia CPT codes listed

4Codes not separately reimbursed

A4305/A4306Elastomeric pump HCPCS noted

3Physical status modifiers with >0 units (P3-P5)

50%Payment for directed physician/CRNA

Policy summary and scope

This is the Plan's anesthesia services reimbursement policy for Commercial and Medicare Advantage markets (applicable in PA, WV, DE and NY as noted) that follows CPT conventions and aligns with CMS guidance (CMS Online Manual Publication: 100-04, Ch.12, Sec.50). It directs payment based on base units, time units (1 time unit = 15 minutes; total minutes reported in the 'days or units' block are converted by The Plan by dividing by 15 and rounding to one decimal place, e.g., 48 minutes = 3.2 time units), and applicable modifiers to denote performer/direction/supervision (for example AA, QK, QX, QY, QZ, G8, G9, AD, QS).

Coverage criteria and adjudication rules

Types of anesthesia eligible for reimbursement

Covered types of anesthesia include the following. Local infiltration (A9270) is considered direct infiltration of the incision/wound/lesion and is not covered as an anesthesia service.

Inhalation anesthesia

Regional anesthesia, including spinal (low spinal, saddle block), epidural (including caudal), nerve blocks (e.g., retrobulbar, brachial plexus), and field blocks

Intravenous anesthesia

Rectal anesthesia

Conscious (moderate) sedation

Eligibility for nerve block/injection anesthesia codes 01991/01992 and local anesthesia exclusion

Anesthesia for diagnostic or therapeutic nerve blocks/injections (CPT 01991, 01992) and local anesthesia rules:

Anesthesia for diagnostic or therapeutic nerve blocks and injections (01991 and 01992) is eligible for reimbursement only when the block or injection is performed by a different provider than the one billing the procedure.

Local anesthesia (A9270) — defined as direct infiltration of the incision, wound, or lesion — is not a covered anesthesia service.

Note: Report units (not minutes) for moderate (conscious) sedation where applicable. Applicable codes referenced in policy include: 01991, 01992, A9270, J0670, J2001, J2795, S0020.

Anesthesia prior to postponement/aborted surgery

Guidance for adjudication when anesthesia is provided prior to postponement, cancellation, or abortion of surgery:

If surgery is cancelled because of the anesthesiologist's preoperative appraisal, reimbursement may be made on the basis of a consultation. Coverage for consultations is determined according to individual or group customer benefits and must be supported by documentation.

When surgery is aborted after general or regional anesthesia induction has taken place, reimbursement is made on the basis of 3 base (basic) units plus time units multiplied by the conversion factor.

If anesthesia is reported under a not otherwise classified (NOC/NOS) code for a case that was postponed or cancelled, the Plan will adjudicate the claim according to policy guidelines and supporting documentation.

Monitoring and intraoperative supportive services (bundling rules)

Monitoring and related intraoperative/supportive services billing and bundling rules:

Monitoring services performed in conjunction with administration of anesthesia are considered part of the global anesthesia allowance and are not separately reimbursable when billed on the same date of service as anesthesia. If monitoring services are itemized on the same date as anesthesia, the Plan will combine charges and reimburse only the anesthesia.

Examples of monitoring/intraoperative supportive services: ECG/EKG monitoring; administration of fluids and/or blood; respiratory function monitoring (oximetry, capnography/end-tidal CO2); temperature; blood pressure; mass spectrometry (Commercial products only).

A participating/network provider may not separately bill the member for monitoring services that are included in the anesthesia allowance.

If monitoring services are independently performed and are distinct from the anesthesia service, report the monitoring service with modifier 59 to indicate it is separate and independent. The medical record must support the use of modifier 59 in accordance with CPT guidelines.

Elastomeric Infusion Pump and Catheter Coverage

Elastomeric infusion pump and catheter coverage and reimbursement rules:

Continuous local delivery of analgesia to operative sites using FDA‑approved elastomeric infusion pumps and associated catheters is an accepted postoperative pain control technique when clinically appropriate.

Reimbursement for catheter insertion and removal to provide continuous delivery of a drug to a surgical site is included in the surgical allowance and is not eligible for separate reimbursement.

Elastomeric infusion pump supplies (HCPCS A4305, A4306) are most commonly reported as facility expenses. When reported by the physician, coverage for these supplies is determined according to individual or group customer benefits.

Only FDA‑approved elastomeric pumps and associated catheters are to be used. Typical use cases include orthopedic, urology, plastic surgery, obstetrical/gynecologic, gastrointestinal, thoracic, and cardiovascular procedures.

Operational payment rules, modifiers, units, and bundling (consolidated)

Comprehensive operational and payment rules that apply across anesthesia services (consolidated):

Reimbursement methodology: Payment is based on relative value units — base (basic) units + time units + eligible modifying units (when appropriate) — multiplied by the anesthesia conversion factor.

Basic unit/value when multiple procedures performed: When multiple surgical procedures are performed, the basic value is the basic value for the procedure with the highest unit value. No separate basic unit value is allowed for second, third, etc. procedures.

Anesthesia time definition and reporting: Anesthesia time begins when the anesthesiologist or CRNA is first in attendance for creating the anesthetic state and ends when no longer in personal attendance (patient may be placed under customary postoperative supervision). Time must be documented on the anesthesia record (not required on the claim) and reported on the claim as actual minutes in the 'days or units' block; the Plan converts minutes to 15‑minute time units, dividing total minutes by 15 and rounding to one decimal place (e.g., 48 minutes = 3.2 time units).

Time reporting for moderate (conscious) sedation: Report units, not minutes, as noted in policy.

Time units, base units, modifying units and payment calculation

Anesthesia time reporting and time units

Time must be indicated on all anesthesia claims and converted to 15‑minute time units; special rule for conscious (moderate) sedation:

Report minutes on claim: Report actual anesthesia time as minutes in the 'days or units' block on the claim.

Conversion to time units: The Plan converts total minutes to time units by dividing total minutes by 15 and rounding to one decimal place (e.g., 48 minutes = 3.2 time units).1 time unit = 15 minutes; total minutes / 15 rounded to one decimal

Conscious sedation reporting: Report units, not minutes, for moderate (conscious) sedation (special billing requirement).

Codes: applicable, not separately reimbursed, modifiers

Applicable anesthesia and related CPT codesCPT

00811	Anesthesia for lower intestinal endoscopic procedures - diagnostic/when screening converted to diagnostic (use PT modifier as applicable)
00812	Anesthesia for lower intestinal endoscopic procedures - screening colonoscopy
01991	Anesthesia for diagnostic or therapeutic nerve blocks and injections (eligible when performed by a different provider)
01992	Anesthesia for diagnostic or therapeutic nerve blocks and injections (eligible when performed by a different provider)
01958	Anesthesia for obstetric procedures (labor)
01960	Anesthesia for labor and delivery
01961	Anesthesia for labor and delivery
01962	Anesthesia for labor and delivery
01963	Anesthesia for labor and delivery
01965	Obstetrical anesthesia

1–10 of 35

1/4

Codes specifically not separately reimbursedCPTNot Covered

99100	Modifying unit - age (not separately reimbursed per policy)
99116	Modifying unit - total body hypothermia (not separately reimbursed per policy)
99135	Modifying unit - controlled hypotension (not separately reimbursed per policy)
99140	Modifying unit - emergency (not separately reimbursed per policy)

Anesthesia modifiers and definitionsModifier

AA	Anesthesia services performed personally by the anesthesiologist
AD	Medical supervision by a physician; more than 4 concurrent anesthesia procedures
G8	Monitored anesthesia care (MAC) for deep complex/complicated or markedly invasive surgical procedures
G9	Monitored anesthesia care for patient with history of severe cardio-pulmonary condition
QK	Medical direction of two, three or four concurrent anesthesia procedures involving qualified individuals
QS	Monitored anesthesia care service (informational)
QX	CRNA service with medical direction by a physician
QY	Medical direction of one CRNA by an anesthesiologist
QZ	CRNA service without medical direction by a physician
59	Distinct procedural service - use to report monitoring/services independent from anesthesia when supported

1–10 of 17

1/2

Dental CDT codesmixed

D9222	Deep sedation/general anesthesia, initial 15 minutes
D9239	IV moderate (conscious) sedation/analgesia, initial 15 minutes
D9223	Deep sedation/general anesthesia, each subsequent 15-minute increment
D9243	IV moderate (conscious) sedation/analgesia, each subsequent 15-minute increment

Elastomeric pump supplies (HCPCS)HCPCS

A4305	Elastomeric infusion pump supply (coverage when reported by physician determined by customer benefits)
A4306	Elastomeric infusion pump supply (coverage when reported by physician determined by customer benefits)

Local anesthesia not coveredHCPCSNot Covered

A9270

Local anesthesia (direct infiltration of incision/wound/lesion) - not a covered service/separately reimbursable

Billing, modifier and documentation actions (what providers must do)

Billing Rule

Report anesthesia time and conversion

Report the actual anesthesia time spent administering anesthesia as minutes in the claim 'days or units' block; the Plan will convert total minutes to time units. Time units = total minutes ÷ 15, rounded to one decimal place. For moderate (conscious) sedation, report units (not minutes).

Conversion example: 48 minutes = 48 ÷ 15 = 3.2 time units

Billing Rule

Do not bill monitoring separately with anesthesia / Use modifier 59 when independent

Monitoring and other supportive services performed as part of anesthesia care are bundled into the anesthesia allowance and are not separately reimbursed when reported on the same date of service. If a monitoring/supportive service is independently performed and clearly distinct from the anesthesia service, it may be reported separately only with modifier 59 and documentation that supports its independent performance.

Key terms and operational definitions

Common billing questions

Q&A — Reporting anesthesia time & monitoring

Quick actionable callouts

Note

Policy updates and material changes

12/2025added

Added 62273, 62281, 62282, 01967-01969; added Epidural Anesthesia Care section; clarified direction for modifiers QK and QY.

04/28/2025clarified

Clarified section for Screening Colonoscopy code 00812.

04/2026revisedLatest

Policy revised (April 2026 revision noted in header).

Policy Summary

PayerHighmark Delaware

PolicyRP-033 Anesthesia Services

Policy CodePolicy RP-033

Change TypeClarifications, additions and administrative review

Effective DateMar 12, 2018

Next Review DateN/A

Key ActionReport actual anesthesia time as minutes in the 'days or units' block so the Plan can convert minutes to time units; report units (not minutes) for moderate sedation.

SourceLink

On This Page

The Plan considers pre-operative and post-operative visits part of the global anesthesia allowance.

Applicable monitoring codes are identified in policy (examples include 36430, 36440, 36450, 36455, 36460, 83789, 93000, 93005, 93010, 93040, 93041, 93042, 94680, 94681, 94690, 94726–94729, 94760–94761). Medicare Advantage applicable subset is noted separately in policy.

Physical status modifiers and modifying units (Commercial only): Physical status modifiers (e.g., P1–P6) are recognized; modifying units for physical status and special circumstances may be applied per policy. The Plan does not separately reimburse for anesthesia add‑on codes 99100, 99116, 99135, or 99140.

Position units: No allowance is made for position. In extenuating circumstances, providers may appeal for consideration by medical review. Up to four additional modifying units may be allowed when the anesthesiologist requests additional units for general anesthesia for congenital cataract extraction; medical records and documentation are required.

Payment rules by performer/direction: Payment differs by whether anesthesia is personally performed, medically directed, or supervised. Physicians must report the appropriate anesthesia modifier to denote service type (examples: AA, AD, G8, G9, QK, QS, QX, QY, QZ). QS is informational only. Providers must report actual anesthesia time on the claim line.

Payment for personally performed anesthesia: Payment is determined by the base unit plus one time unit per 15 minutes when the physician personally performs the entire service alone, or meets specified teaching/continuous involvement scenarios with residents/CRNAs/AAs per policy. Documentation is required when duplicate payment to both physician and CRNA/AA is claimed.

Payment for directed anesthesia (medical direction): Payment for physician's directed service is 50% of the allowance for the service performed by the physician alone when medical direction criteria are met (the physician directs qualified individuals in two, three, or four concurrent cases and performs required functions such as pre‑anesthetic exam, prescribing plan, personally performing most demanding procedures, monitoring, remaining available, and providing post‑anesthesia care). Documentation must support direction/supervision activities.

Anesthesia modifiers and direction/supervision reporting: Use the appropriate modifiers to denote personally performed (AA), medical supervision of >4 cases (AD), monitored anesthesia care (G8/G9/QS), medical direction of 2–4 concurrent procedures (QK), CRNA service with medical direction (QX), medical direction of one CRNA (QY), and CRNA without medical direction (QZ).

Monitoring services billed with anesthesia: If monitoring services are billed the same day as anesthesia and are not independent, they will be combined with anesthesia payment; if independently performed and distinct, report with modifier 59 and ensure medical record supports distinct service.

Labor and delivery anesthesia (Commercial only): Specific labor and delivery billing guidance applies (Commercial only). Physical status modifiers and other Commercial‑only modifiers/units referenced in policy apply to Labor & Delivery per the Plan's Commercial rules.

Codes not separately reimbursed (modifying units): The Plan does not separately reimburse for CPT codes 99100, 99116, 99135, or 99140. These are considered modifying units already captured in the anesthesia allowance when applicable.

Anesthesia base unit/reimbursement rules for multiple procedures: Reiterate that base units are assigned to the highest‑value procedure only; additional procedures do not receive separate base unit reimbursement.

Direction of Anesthesia and Modifier Use: Providers must report proper modifiers to reflect whether the service was personally performed, medically directed, or supervised. Failure to report correct modifiers or to document direction/supervision and time may result in denial or downcoding.

Calculation of reimbursement and Base Unit and Multiple Procedure Rule

How reimbursement is calculated and rule when multiple procedures performed:

Calculation method: Reimbursement is calculated using relative value units: base units plus time units and eligible modifying units multiplied by a monetary conversion factor.

Multiple procedure base unit rule: When multiple surgical procedures are performed, the basic (base) unit value reimbursed is that of the procedure with the highest base unit value; base units for second, third, etc., procedures are not reimbursed.

Modifying units reimbursement and Modifying Units (Flat Fee Codes)

Rules for modifying (flat‑fee) circumstance codes and handling for Medicare Advantage/NY products and criteria for specific codes:

Flat-fee modifying codes not reimbursed separately: The Plan does not separately reimburse for codes 99100, 99116, 99135, or 99140 (these are flat‑fee modifying circumstance codes).

Medicare Advantage and NY exceptions: Medicare Advantage and New York products do not separately reimburse 99100, 99116, 99135, or 99140.

99100 age criteria: Code 99100 (age) may be allowed for patients under 1 year of age or 71 years of age or older.patient age <1 year OR >=71 years

99140 emergency criteria: Code 99140 (emergency) may be reimbursed for services reported as emergency except for normal vaginal delivery.

99116 and 99135 allowances: Codes 99116 (total body hypothermia) and 99135 (controlled hypotension) may be allowed when requested by the doctor.

Physical Status Modifiers and Allowed Units (Commercial Only)

Physical status modifiers P1–P6 definitions and allowed units (Commercial only):

P1: Physical Status I (P1): Units allowed = 0; normally healthy patient.

P2: Physical Status II (P2): Units allowed = 0; mild to moderate systemic disturbance.

P3: Physical Status III (P3): Units allowed = 1; severe systemic disease.

P4: Physical Status IV (P4): Units allowed = 2; severe systemic disorder, life threatening.

P5: Physical Status V (P5): Units allowed = 3; moribund patient.

P6: Physical Status VI (P6): Units allowed = 0; declared brain-dead organ donor.

Common monitoring examples: ECG/EKG monitoring, pulse oximetry (oxygen saturation), end-tidal CO2 monitoring (capnography), blood pressure, temperature, respiratory monitoring.

If itemized charges for monitoring/support are submitted the Plan will combine them with the anesthesia charge and reimburse only the anesthesia.

When modifier 59 is used, the patient medical record must support its use per CPT guidance.

Participating/network providers may not separately bill the member for bundled monitoring services.

Documentation Required

Documentation for directed anesthesia

Directed anesthesia must be supported by the anesthesia record and clinical documentation showing the physician's pre-anesthetic exam, prescribed anesthesia plan, participation in induction/emergence or the most demanding portions of care, monitoring, and post-anesthesia care. When physician and CRNA both bill full fees for the same case, documentation from both providers must support payment splits or full fees.

Required documentation: pre-anesthetic examination and evaluation, anesthesia plan, record of personal participation in induction and/or emergence when billed, monitoring notes, and post-anesthesia care.
Identify physicians in group practices explicitly in the record to support who performed or directed services.
When payment is requested for both physician and CRNA full fees, submit documentation from both providers that supports medical necessity for dual payment and the distinct services performed.

Denial Risk

Obstetrical add-on codes: billing and rejection risk

Obstetrical anesthesia add-on codes must never be billed as standalone services and must be reported on the same date of delivery as the primary anesthesia code. Mismatched dates, missing the required primary code, or billing these add-ons alone will result in claim rejection or denial.

Obstetrical add-on codes: 01967, 01968, 01969
These codes must accompany the primary anesthesia code and share the delivery date; omission of the primary code or a different date may cause rejection.

Billing Rule

Elastomeric pump and catheter billing

Catheter insertion and removal for continuous local analgesia delivered via elastomeric pumps are included in the surgical allowance and are not separately reimbursable. Elastomeric pump supplies (A4305, A4306) are most commonly reported by facilities; physician reporting is subject to customer or group benefits.

Catheter insertion/removal included in surgical allowance; do not bill separately.
Elastomeric pump supply codes: A4305, A4306 — usually facility supplies; physician coverage depends on individual/group customer benefits.

Billing Rule

Do not separately reimburse listed modifying unit codes

The Plan will not separately reimburse the listed modifying unit codes. Exceptions for Medicare Advantage or New York regional rules may apply as noted in policy.

Do not separately reimburse: 99100, 99116, 99135, 99140
Medicare Advantage / New York: follow regional/MA-specific guidance where applicable.

Billing Rule

Dental anesthesia billing units

For dental anesthesia, bill the initial 15-minute unit on one line and subsequent 15-minute increments on separate lines using the appropriate CDT codes and units.

Initial 15 minutes: D9222 or D9239
Subsequent 15-minute increments: D9223 or D9243

Billing Rule

Aborted or cancelled surgery billing

When surgery is aborted or cancelled, follow these billing rules: if surgery is cancelled because of the anesthesiologist's preoperative appraisal, reimbursement may be considered as a consultation per member benefits. If surgery is aborted after induction, reimbursement is based on 3 basic units plus time units multiplied by the conversion factor. Documentation of events and anesthesia records is required.

Cancelled due to anesthesiologist pre-op appraisal: may bill as consultation (coverage determined by member benefits).
Aborted after induction: reimbursement = 3 base units + time units × conversion factor; submit anesthesia record.
If anesthesia is reported under an NOC/NOS code for postponement, the Plan will adjudicate per policy guidelines.
Detailed documentation and medical records must accompany appeals or requests for consideration.

Billing Rule

Report appropriate anesthesia modifiers

Append the appropriate anesthesia modifiers to claim lines to denote who performed, directed, or supervised the service and to indicate patient physical status. QS is informational only and time must still be reported; other modifiers affect payment methodology.

Key anesthesia modifiers: AA (anesthesiologist performed personally), AD (medical supervision >4 concurrent procedures), QK (medical direction of 2–4 concurrent CRNAs), QX (CRNA service with physician direction), QY (medical direction of one CRNA), QZ (CRNA service without direction), G8 (MAC for deep complex procedures), G9 (MAC for severe cardio-pulmonary condition), QS (monitored anesthesia care — informational).
Physical status modifiers: P1, P2, P3, P4, P5, P6 — report as applicable.
QS modifier is informational only; actual anesthesia time must still be reported on the claim line.
When reporting directed/delivery scenarios, ensure modifier use is accompanied by supporting documentation per policy.

06/2022removed

Removed CPT 94770 and 94750 and removed Medicare Advantage Medical Policy N-118.

12/2021revised

Added note that the Plan will not separately reimburse codes 99100, 99116, 99135, and 99140.

10/2021added

Added NY region applicability with note for NY under Modifying Units section.

02/2024administrative

Administrative policy review with no changes in policy direction.

08/2019added

Added Dental, Labor and Delivery guidance to policy (Dental anesthesia CDT billing rules and obstetrical anesthesia add-on code rules were added).

10/2019revised

Added additional verbiage related to Dental, Labor and Delivery.

03/2018added

Implementation / Issue date (Effective March 12, 2018).