CurrentMass General Brigham Health PlanPolicy N/A

Anesthesia Services reimbursement

This policy governs Mass General Brigham Health Plan reimbursement for general and regional anesthesia and related supportive services (including CRNA supervision/direction) performed in conjunction with covered obstetrical, surgical, and medical procedures for plan members and participating providers.

Policy Summary

PayerMass General Brigham Health Plan

PolicyAnesthesia Services reimbursement

Policy CodePolicy N/A

Change TypeAnnual review — no material change

Effective DateN/A

Next Review DateJan 1, 2025

Key ActionVerify member eligibility, referrals/authorizations, and applicable modifiers before submitting anesthesia claims; submit total minutes in the designated minute field per policy rules.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

00100-01999Anesthesia CPT code range referenced for reimbursement

15 minAnesthesia time unit length

01967 → 20Vaginal delivery neuraxial cap

01968 → 24Cesarean delivery cap

Base+Time x CFPayment formula

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Coverage and Reimbursement Conditions

Coverage criteria for anesthesia services

Covered when ALL of the following are met:

Anesthesia services involving administration of anesthesia using anesthesia five-digit CPT codes 00100-01999 are billed by a participating provider and meet plan, coding, and documentation requirements.

ALL of the following

Payment is calculated as (Anesthesia Base Units + Time Units) x Conversion Factor using ASA base units for the primary procedure and provider-reported anesthesia time units.
Submit total anesthesia time in minutes in the designated electronic minute field using three digits (e.g., 022 for 22 minutes); do NOT submit time units or add base units to total minutes.
Anesthesia time units equal 15-minute segments; partial 15-minute increments are rounded down for 7.49 minutes or less and rounded up for 7.50 minutes or more. Discontinuous blocks may be billed only if continuous monitoring is maintained and documentation supports the aggregated time.

ALL of the following

Vaginal delivery neuraxial labor analgesia (CPT 01967) is capped at a maximum of 20 units (300 minutes), including base time.
Cesarean delivery anesthesia (CPT 01968) is capped at a maximum of 24 units (360 minutes); when both 01967 and 01968 are reported the combined cap applies.

ALL of the following

Medical records must support billed anesthesia time and monitoring (including documentation to support any aggregation of discontinuous time blocks).
All claims are subject to audit and medical records may be requested to substantiate billed services and time.

ALL of the following

Do NOT bill the following
- Anesthesia performed by the surgeon (Modifier 47).
- Anesthesia stand-by services.
- Anesthesia qualifiers (CPT 99100-99140).
- Anesthesia physical status modifiers (P1-P6).
- CPT codes designated by ASA as 'anesthesia care not normally required' or not a primary procedure code.
- CRNA services performed by salaried facility employees.

ALL of the following

Use appropriate anesthesia-specific modifiers (e.g., AA, AD, QZ and other applicable modifiers) as applicable; modifier presence or absence may affect payment per plan rules.
When multiple surgical procedures are performed during a single anesthetic, report only the anesthesia code with the highest base unit value and report combined total minutes for all procedures.

ALL of the following

ANY of the following
- CPT 36556 (central venous pressure monitor insertion), CPT 36620 (intra-arterial monitoring line insertion), and CPT 93503 (Swan-Ganz catheter placement) may be reimbursed separately per the appropriate fee schedule.
- Certified Registered Nurse Anesthetists (CRNA) services are reimbursable according to applicable fee schedule and provider status.

General reimbursement conditions

Policy disclaimers and applicability:

Claims payment is subject to member eligibility and benefits on the date of service, coordination of benefits, referral/authorization/notification and utilization management guidelines when applicable, adherence to plan policies and provider contractual agreement, and claims editing logic.

This guideline is informational; in the event of a conflict between this payment guideline and a provider's contract, the provider agreement terms prevail.

Providers are reimbursed according to the plan's network provider reimbursement or contracted rates; covered services and member liabilities are determined by the member's benefit plan.

All claims are subject to audit and medical records may be requested; payment rationale and claim adjudication consider contracted terms, benefit scope, clinical rationale, industry-standard edits, and coding conventions.

Codes, Modifiers, and Time Units

Covered CPT CodesCPTCovered

00100-01999	Anesthesia CPT codes for which reimbursement is provided; use appropriate anesthesia five-digit CPT codes.
01967	Neuraxial labor analgesia/anesthesia for planned vaginal delivery — subject to time unit cap.
01968	Anesthesia for cesarean delivery — subject to combined time unit cap with 01967.

Anesthesia-specific Modifiers and Crosswalk Reference CodesModifier

QZ	CRNA service; without medical direction by a physician. QZ modifier updated in document.
AA	Anesthesia services performed personally by physician; reimbursement = 100% of anesthesia allowable.
AD	Medical supervision by a physician for more than 4 concurrent procedures; reimbursement = base units.
JQx	CRNA service with medical direction by a physician; reimbursement = 50% of anesthesia allowable.
JQy	Medical direction of one CRNA by an anesthesiologist; reimbursement = 50% of anesthesia allowable.
4	Anesthesia performed by surgeon; no additional reimbursement for anesthesia by a surgeon, assistant surgeon, nursing staff, or any other non-anesthesiologist professional during a procedure.

Primary Coding References (neutral)mixed

ASA Crosswalk	American Society of Anesthesiology Crosswalk: A Guide for Surgery/Anesthesia CPT Codes.
CMS Chapter 12	CMS Medicare Claims Processing Manual Chapter 12 — Payment for Anesthesiology Services.
NCCI Manual	National Correct Coding Initiative Policy Manual for Medicare Services — Anesthesia Services.
MassHealth guidance	MassHealth Anesthesia Service Codes Spreadsheet and 101 CMR 316.00: Rates for Surgery and Anesthesia Services.

Obstetrical anesthesia time caps — key facts

01967 (neuraxial labor analgesia — planned vaginal delivery)Capped at a maximum of 20 time units (300 minutes); maximum units include base time.

01968 (anesthesia for cesarean delivery)Capped at a maximum of 24 time units (360 minutes); maximum units include base time and apply when billed following 01967.

Combined-cap ruleWhen 01967 and 01968 are both reported (e.g., vaginal labor that converts to cesarean), the combined maximum is 24 units (360 minutes) total (base + time) — 01968 is not reimbursable when billed alone in this context and is submitted in addition to 01967 per guidelines.

Primary coding references

American Society of Anesthesiology (ASA) Crosswalk‘American Society of Anesthesiology Crosswalk: A Guide for Surgery/Anesthesia CPT Codes’ — used as a primary crosswalk reference for anesthesia CPT coding.

What Providers Must Do

Prior Authorization

Referral/Authorization required — check the plan Referral Grid

Various services and procedures require referral and/or authorization; refer to the plan resources and the Referral/Authorization grid to confirm whether a specific anesthesia-related service needs prior referral or authorization before scheduling or claim submission.

Locate referral and authorization requirements via the plan's Referral Grid or provider resources referenced in the payment policy.

Billing Rule

Claims prerequisites — eligibility, COB, referrals, documentation, and edits

Claims payment is subject to member eligibility and benefits on the date of service, coordination of benefits, referral/authorization/notification and utilization management when applicable, adherence to plan policies and procedures, claims editing logic, and the provider's contractual agreement; ensure required documentation is available as claims are subject to audit.

Definitions and Reference Terms

Anesthesia Time Unit — definition and rounding

Unit lengthOne anesthesia time unit equals a 15-minute segment during which an anesthetic is administered.

Rounding rulesPartial 15-minute increments of 7.49 minutes or less are rounded down; 7.50 minutes or more are rounded up.

Minimum billing ruleIf less than 7.50 total minutes of a unit are billed, it will be reimbursed as one billable time unit.

Discontinuous Anesthesia Time — aggregation rules

Aggregation allowanceDiscontinuous blocks of anesthesia time may be aggregated when the anesthesiologist provides continuous anesthesia care within the surrounding periods and continuous monitoring is maintained.

Documentation requirementMedical record must document the continuous and discontinuous periods so an auditor can reconcile the reported total anesthesia time to the segments when the anesthesiologist was present.

Policy Revision History

2010-08-03published

Initial Provider Payment Guidelines entry in document history.

2012-02-01updated

Document updated (listed in revision history).

2012-03-16updated

Document updated (listed in revision history).