CurrentMass General Brigham Health PlanPolicy N/A

Anesthesia

Defines Mass General Brigham Health Plan reimbursement, coding, and billing rules for administration of general and regional anesthesia, CRNA supervision/direction, related monitoring and post-operative pain management services and excluded anesthesia-related services.

Policy Summary

PayerMass General Brigham Health Plan

PolicyAnesthesia

Policy CodePolicy N/A

Change TypeAnnual reviews; rebrand/update (no material coverage changes)

Effective Date

Next Review Date

Key ActionSubmit electronic claims using the designated three-digit minute field with total minutes (e.g., 022) and document monitoring to support any aggregated discontinuous anesthesia time.

SourceLink

POLICY UPDATE CHANGES

January 1, 2023 document rebrand and updated CPT grid and references.

January 1, 2024 annual review noted no policy change.

January 1, 2025 annual review noted no policy change.

00100-01999Anesthesia CPT code range applicable

20 / 300min01967 cap (vaginal delivery)

24 / 360min01967 + 01968 combined cap

101996 units payable per post-op day

Mass General Brigham Health Plan reimburses participating providers for administration of general and regional anesthesia and for supervision/direction of CRNAs when furnished by an anesthesiologist in conjunction with covered obstetrical, surgical, or medical procedures. Reimbursement uses the ASA anesthesia base unit system plus time units (one 15-minute segment) multiplied by a conversion factor according to the formula: (Anesthesia Base Units + Time Units) X Conversion Factor. Providers must bill using five-digit anesthesia CPT codes (00100-01999) and submit total anesthesia time in minutes in the designated three-digit minute field (do NOT submit time units).

Services that are incidental, mutually exclusive, integral to the primary service, or part of a global allowance are not separately reimbursable. Specific not-reimbursed items include anesthesia by a surgeon (Modifier 47), anesthesia stand-by, anesthesia qualifiers (99100-99140), anesthesia physical status modifiers (P1-P6), and certain E/M or sedation codes when bundled with included anesthesia services. Post-operative and pain management reporting have specific rules and limits (see next paragraph).

Obstetrical and post-operative rules and caps: neuraxial/epidural labor analgesia code 01967 is capped at 20 units (300 minutes) including base units; when a planned vaginal delivery converts to cesarean, 01968 may be submitted in addition to 01967 and the combined 01967+01968 is capped at 24 units (360 minutes) including base units (01968 is not reimbursable when billed alone). Daily hospital management code 01996 is separately payable only on days subsequent to surgery (one unit per post-operative day); continuous block codes (64416/64446/64448) reported on the day of surgery preclude additional daily pain-management reporting. Claims are subject to plan edits, contractual rates, and audit; providers may be asked to submit medical records to support billed anesthesia time and services.

Policy status: CURRENT. Last review date: 2025-01-01.

Key thresholds and quick facts

Anesthesia CPT code range applicable00100-01999

01967 (vaginal neuraxial labor) cap20 units (300 minutes) — Base + Time maximum

01967 + 01968 (labor + cesarean) combined cap24 units (360 minutes) combined — Base + Time maximum

01996 units per post-operative day1 unit per post-operative day; not payable on day of surgery when catheter used for surgical anesthetic

Anesthesia time rounding rulesTime unit = 15-minute segment; partial increments rounded down <= 7.49 min, rounded up >= 7.50 min; if less than 7.50 total minutes billed, reimbursed as one time unit

Claim submission for timeSubmit total minutes in designated minute field (three digits); do NOT submit time units

When services are reimbursed (criteria)

General reimbursement rule

Reimbursed when ALL of the following are met:

Anesthesia provider: Anesthesia (general or regional) administered by an anesthesiologist or CRNA supervised/directed by an anesthesiologist
In conjunction with covered procedure: Service is in conjunction with a covered obstetrical, surgical, or medical procedure per member's benefit plan
Billing codes and reporting: Provider bills using five-digit anesthesia CPT codes (00100-01999) and follows ASA base unit & time unit reporting
Plan edits and contracts: Claims are subject to plan payment edits and the provider's contractual reimbursement rates

Time reporting and unit calculation

Time and payment calculation rules (ALL apply):

Time and unit calculation

Payment formula: Anesthesia reimbursement = (Anesthesia Base Units + Time Units) X Conversion Factor
Time unit definition and rounding: Anesthesia time unit = one 15-minute segment; partial increments rounded down if <= 7.49 minutes, rounded up if >= 7.50 minutesPartial 15-minute increments: <=7.49 min round down; >=7.50 min round up
If less than 7.50 total minutes of a unit are billed, reimbursed as one billable time unit
Minimum billing unit guidance: If less than 7.50 total minutes of a unit are billed, it will be reimbursed as one billable time unit

Obstetrical anesthesia caps

Maximum time/unit caps (ALL apply):

01967 cap: Vaginal delivery neuraxial/epidural labor code 01967 capped at maximum of 20 units (300 minutes) including base units20 units (300 minutes) including base units
01967+01968 combined cap: Cesarean delivery following neuraxial labor code 01968 combined with 01967 capped at maximum of 24 units (360 minutes) including base units24 units (360 minutes) combined including base units
01968 submitted in addition to 01967 when planned vaginal delivery turns into cesarean; 01968 not reimbursable when billed alone
01968 submission rule: 01968 is submitable in addition to 01967 when planned vaginal delivery turns into cesarean; 01968 not reimbursable when billed alone

Post-operative inpatient pain management

When payable (ALL apply):

Post-operative pain management rules

01996 payable days: CPT 01996 payable on days subsequent to surgery (inappropriate on day of surgery when catheter was used for surgical anesthetic)
Submit only one unit per post-operative day regardless of number of visits; reimbursement is one flat fee
01996 single unit: 01996: Submit only one unit per post-operative day regardless of number of visits; reimbursement is one flat fee1 unit per post-operative day
6232x injections on day of surgery: 62320-62321 and 62322-62323 may be submitted for post-operative pain management on day of surgery when NOT used as surgical anesthetic; report with modifier 59 and one unitReport with modifier 59 and one unit

Provider coding and reporting rules

All of the following coding rules apply:

Highest base-unit code only: Report only the anesthesia code (00100 series) with the highest base unit value when multiple surgical procedures performed during single anesthetic; time reported is combined total minutes
Discontinuous blocks billing condition: Bill discontinuous blocks of anesthesia time only if continuous monitoring is documented within blocks
Medical record documentation must support aggregated time for auditor review
Modifier usage: Use CMS/CPT guidelines for modifier usage; absence/presence may affect payment or denial
Append appropriate anesthesia-specific modifiers (AA, AD, QK, QX, QY, QZ, 47) as applicable

Code lists and status

Anesthesia CPT codes (covered for administration of anesthesia)CPTCovered

00100-01999

Anesthesia five-digit CPT codes for administration of anesthesia

Obstetrical anesthesia codes and notesCPTCovered

01960	Anesthesia for vaginal delivery only; denied when submitted with CPT 01967
01961	Anesthesia for cesarean delivery only; denied when submitted with CPT 01967-01968
01967	Neuraxial labor analgesia/anesthesia for planned vaginal delivery; time unit cap applies: Base + Time maximum 20 units (300 minutes)
01968	Anesthesia for cesarean delivery following neuraxial labor analgesia; submit in addition to 01967 when planned vaginal delivery turns into cesarean; not reimbursable when billed alone; combined cap with 01967 to 24 units (360 minutes)
01969	Anesthesia for cesarean hysterectomy following neuraxial labor analgesia; submit in addition to CPT 01967

Post-operative pain management and related injectionsCPTCovered

01996	Daily hospital management of epidural/subarachnoid continuous drug administration; separately payable on days subsequent to surgery; one unit per post-operative day; not payable on day of surgery when catheter used for surgical anesthetic
62320	Injection(s), interlaminar epidural/subarachnoid cervical or thoracic; submit for post-operative pain management on day of surgery when NOT used as surgical anesthetic; report with modifier 59 and one unit
62321	See 62320
62322	Injection(s), interlaminar epidural/subarachnoid lumbar or sacral (caudal); submit for catheter insertion for post-operative pain management on day of surgery when NOT used as the surgical anesthetic; report with modifier 59 and one unit
62323	See 62322
64416	Continuous block code; when reported on day of surgery, no additional reporting of daily pain management is allowed
64446	Continuous block code; see 64416
64448	Continuous block code; see 64416
99231	Subsequent hospital care; submit for inpatient post-operative pain management services not described above; one unit per day
99232	See 99231

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1/2

Separately payable procedures (based on appropriate fee schedules)CPTCovered

93503	Placement of a Swan-Ganz catheter for monitoring purposes
36620	Insertion of an intra-arterial monitoring line during surgery
36556	Insertion of a central venous pressure monitor during surgery

Modifiers (anesthesia-specific)Modifier

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 = 3 base units
QK	Medical direction of two, three or four concurrent anesthesia procedures; reimbursement = 50% of anesthesia allowable
QX	CRNA service with medical direction by a physician; reimbursement = 50% of anesthesia allowable
QY	Medical direction of one CRNA by an anesthesiologist; reimbursement = 50% of anesthesia allowable
QZ	CRNA service without medical direction by a physician; no impact on reimbursement
47	Anesthesia performed by surgeon; no additional reimbursement for anesthesia by surgeon or non-anesthesiologist

Not reimbursed / ExclusionsCPT|ModifierNot Covered

Modifier 47	Anesthesia by surgeon — does not reimburse
99100-99140	Anesthesia qualifiers — not reimbursed
P1-P6	Anesthesia physical status modifiers — not reimbursed
99151-99157	Moderate (conscious) sedation when billed with a procedure that includes conscious sedation — not reimbursable

Billing, documentation, and denial risk

Billing Rule

Use designated minute field and format

Submit electronic claims using the designated minute field with three digits (for example, 22 minutes should be submitted as 022). Use the anesthesia five‑digit CPT codes (00100-01999) and report total minutes from the beginning to the end of the anesthesia service in that designated minute field to avoid overpayment and audit recovery.

Affected codes: 00100-01999
Submit total minutes in the three-digit minute field (e.g., 022)

Billing Rule

Report only highest base-unit anesthesia code for multiple procedures

When multiple surgical procedures are performed during a single anesthetic administration, report only the anesthesia code with the highest ASA base unit value. Report the combined total minutes for all procedures as the anesthesia time.

Affected codes: 00100-01999
Combine and report total minutes for all procedures

Documentation Required

Document discontinuous anesthesia time and monitoring

Bill discontinuous blocks of anesthesia time only when continuous monitoring is provided within those blocks and the medical record documents continuous monitoring so an auditor can verify the aggregated time. Documentation must show the continuous and discontinuous periods that sum to the reported total anesthesia time.

Emphasize continuous monitoring documentation to support aggregation of discontinuous blocks

Billing Rule

Modifier usage affects reimbursement

Append appropriate anesthesia-specific modifiers to anesthesia service codes and related E/M codes. Presence or absence of these modifiers can affect claim payment or result in denial; follow CMS/CPT guidance for modifier usage.

AA
AD
QK
QX
QY
QZ
47
Modifier presence or absence may change payment or cause denial

Denial Risk

Obstetrical code pairing denials

Certain obstetrical anesthesia code pairings will be denied. Adhere to the specified submission rules for neuraxial labor and cesarean codes: 01967 has a time/unit cap and may be combined with 01968/01969 under rules; 01968 is payable only when submitted in addition to 01967 (not reimbursable when billed alone); specific disallowed pairings (e.g., 01960 with 01967; 01961 with 01967-01968) will be denied.

Affected codes: 01960, 01961, 01967, 01968, 01969
01967 capped at 20 units (300 minutes) including base units
01968 submit in addition to 01967 when planned vaginal delivery converts to cesarean; 01968 not reimbursable when billed alone; combined 01967+01968 capped at 24 units (360 minutes)
01960 denied when submitted with 01967; 01961 denied when submitted with 01967-01968
01969 submit in addition to 01967

Billing Rule

Post-operative pain management billing limits

Daily hospital management of continuous epidural/subarachnoid drug administration (01996) is separately payable only on days subsequent to surgery and is not payable on the day of surgery when the catheter was used to deliver the surgical anesthetic. Continuous block codes reported on the day of surgery preclude additional daily pain management reporting.

Affected codes: 01996, 64416, 64446, 64448
01996: one unit per post-operative day; not payable on day of surgery when catheter was used for the surgical anesthetic
Continuous block codes (64416, 64446, 64448) on day of surgery preclude additional daily pain management reporting

Documentation Required

Medical records subject to audit

All claims are subject to audit. Providers may be asked to submit medical records to support billed anesthesia time, monitoring, and services; retain documentation to support time reporting and modifier use.

Medical records may be requested to support billed anesthesia time and services

OpenPayer

Anesthesia

Policy summary

When services are reimbursed (criteria)

Code lists and status

Billing, documentation, and denial risk

Key terms

Policy changes and reviews