CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Anesthesia Billing and Reimbursement Policy

Defines billing, coding, documentation and reimbursement rules for anesthesia services for providers rendering services to Neighborhood Health Plan of Rhode Island members across listed products; applies to in-network and out-of-network providers and covers anesthesiologists and CRNAs.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyAnesthesia Billing and Reimbursement Policy

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionVerify member eligibility, coverage and authorization prior to rendering anesthesia services.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1515-minute billing unit

420 min01967 time cap

60 min01968 time cap

80%CRNA payment percent

7+Non-reimbursable items

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Anesthesia coverage and billing criteria

Neighborhood will reimburse covered, medically necessary anesthesia services when performed by qualified and licensed MDs and CRNAs; specific billing and reimbursement rules follow.

Services must be covered, medically necessary, and performed by a qualified and licensed medical doctor (anesthesiologist) or certified registered nurse anesthetist (CRNA). Out-of-network providers may require separate authorization when billing separately.

Billing and payment are based on: Time units + Base units x Anesthesia Conversion Factor. Neighborhood uses CMS base unit values. Do not submit base unit values in the total minutes/units field on a claim (base units are automatically calculated).

Time reporting and unit conversion: Submit 1 unit for every 15-minute interval; round down (do not bill) for 1–7 minutes; round up to the next unit for 8–14 minutes; time when the anesthesiologist is not in personal attendance is non-billable. Anesthesia start time is defined as the time the anesthesiologist begins preparation of the patient; anesthesia end time is defined as when the patient is placed under post-operative care.

Modifiers and payment adjustments must be submitted to indicate performance/supervision. Required modifiers include AA, QZ (personally performed), and QK/QX/QY (medical direction/supervision) and will affect allowance calculations; claims may deny if modifiers are missing, invalid, or in the wrong position.

Global anesthesia care includes services integral to the surgical procedure and the listed perioperative monitoring and management items (e.g., airway management, monitoring of EKGs, ventilator measurements, intraoperative medication administration, local anesthesia during surgery, transfusion monitoring) and are not reimbursed separately.

Multiple or duplicate anesthesia services on the same day: when multiple anesthesia services are administered on the same date of service, submit only the service with the highest base-unit value and report the total time spent for all procedures; duplicate services will not be reimbursed.

Non-reimbursable services include services billed by anesthesia assistants; CRNA services performed by salaried facility employees; services provided by students; post-operative management on the same day as the surgical procedure for routine pain; anesthesia standby; anesthesia by the operating surgeon; anesthesia for procedures not designated as requiring anesthesia; and anesthesia for non-covered surgical procedures.

Credentialing and provider identification: CRNAs must be individually credentialed to receive reimbursement; claims must reflect the rendering provider and appropriate NPI as required by payer policy.

Documentation requirements to support billing: an anesthesia record documenting services performed and exact time spent, member identifiers on all pages, rendering practitioner credentials and legible signature/date, and legible documentation are required.

Anesthesia coverage and documentation criteria

Coverage stance and required documentation for anesthesia services

Non-reimbursable services: Do not bill for services listed as non-reimbursable. Examples: services billed by anesthesia assistants; CRNA services performed by salaried facility employees; services provided by students; post-operative management on the same day as the surgical procedure for routine pain; anesthesia standby; anesthesia provided by the operating surgeon; anesthesia for procedures not designated as requiring anesthesia; anesthesia for non-covered surgical procedures.

General documentation requirements: The anesthesia record must document the anesthesia services performed, including the exact time spent performing anesthesia services; member identifying information must be present on all pages; the rendering practitioner/qualified healthcare professional must note credentials and legibly sign and date the record; documentation must be legible.

Medical direction documentation: For each anesthesia procedure, the anesthesiologist must document that he/she performed: 1) the pre-anesthetic examination and evaluation; 2) prescribed the anesthesia plan; 3) personally participated in the most demanding procedures of the anesthesia plan, including, if applicable, induction and emergence; 4) ensured that any procedure in the anesthesia plan not performed by the anesthesiologist was performed by a qualified anesthetist; 5) monitored the course of anesthesia administration at frequent intervals; 6) remained immediately physically present and available for immediate diagnosis and treatment of emergencies; and 7) provided the indicated post-anesthesia care.

Procedure Codes, Modifiers, Time Conversion and Caps

Anesthesia CPT/HCPCS Codes (primary)mixedCovered

00100-00936	Anesthesia procedure range
00940-01999	Anesthesia procedure range
62273	Spinal injection/related anesthesia code
99100-99150	Qualifying circumstance/add-on anesthesia codes range
01960	Anesthesia for vaginal delivery
01961	Anesthesia for cesarean delivery
01967	Neuraxial labor analgesia/anesthesia for planned vaginal delivery (obstetrical)
01968	Anesthesia for cesarean delivery following neuraxial labor analgesia/anesthesia (add-on)
01969	Monitored anesthesia care (obstetrical add-on)

Required/Recognized ModifiersModifier

AA	Anesthesia services personally performed by anesthesiologist (reimbursement = 100% of allowable)
AD	Medical supervision by a physician, more than four concurrent anesthesia procedures (reimbursement = max 3 base units + time units)
QK	Medical direction of two, three or four concurrent anesthesia procedures (reimbursement = 50% of allowable)
QY	Medical direction of one CRNA by anesthesiologist (reimbursement = 50% of allowable)
QX	Qualified non-physician anesthetist with medical direction by physician (reimbursement = 80% of the payment made for the QK or QY claim)
QZ	CRNA service, without medical direction by anesthesiologist (reimbursement = 80% of allowable)
P1	Physical status modifier: Normal healthy patient
P2	Physical status modifier: Patient with mild systemic disease
P3	Physical status modifier: Patient with severe systemic disease
P4	Physical status modifier: Patient with severe systemic disease that is a constant threat to life

1–10 of 12

1/2

Qualifying Circumstance Add-on Codes (bill when appropriate)CPT

99100	Anesthesia for patient of extreme age (under 1 year, over 70 years)
99135	Anesthesia complicated by utilization of controlled hypotension
99116	Anesthesia complicated by utilization of total body hypothermia
99140	Anesthesia complicated by emergency conditions

HCPCS D-codes (oral surgery only)HCPCSCovered

D9220	General anesthesia — not otherwise specified (D-codes covered only for oral surgery)
D9221	General anesthesia for dental procedures — hospital/facility (D-codes covered only for oral surgery)

Non-reimbursable Service CategoriesmixedNot Covered

	Services billed by anesthesia assistants
	CRNA services performed by salaried facility employees
	Services provided by students
	Anesthesia standby
	Anesthesia by the operating surgeon
	Anesthesia for procedures not designated as requiring anesthesia
	Anesthesia for non-covered surgical procedures

Provider Responsibilities and Non-Reimbursable Items

Prior Authorization

Verify eligibility, coverage and authorization before services

It is the provider's responsibility to verify eligibility, coverage and authorization criteria prior to rendering services; verify member benefits, network status, and any required authorizations before scheduling or performing anesthesia services. Out-of-network providers may require separate authorization when billing separately.

Confirm member eligibility and benefits prior to service.
Obtain and verify any required prior authorization for anesthesia services.
Verify provider network status and whether separate authorization is required for out-of-network billing.

Billing Rule

Do not bill listed non-reimbursable anesthesia services

Do not bill for services identified as non-reimbursable in the policy; claims for these services are not payable and may be denied if submitted.

Services billed by anesthesia assistants
CRNA services performed by salaried facility employees
Services provided by students
Post-operative management on the same day as the surgical procedure for pain
Anesthesia standby
Anesthesia by the operating surgeon
Anesthesia for procedures not designated as requiring anesthesia
Anesthesia for non-covered surgical procedures

Key Definitions and Documentation Requirements

inv-10: Anesthesia start time definition

DefinitionAnesthesia start time is the time the anesthesiologist begins preparation of the patient.

inv-11: Anesthesia end time definition

DefinitionAnesthesia end time is the time when the patient is placed under post-operative care.

inv-12: Rendering provider — billing under actual rendering provider

Rendering provider requirementAll anesthesia claims must be billed under the name and NPI of the provider who actually rendered the service; 'incident to' billing for anesthesia is not recognized.

Provider scopeAll providers should render services based on the scope of their particular license.

inv-13: General documentation requirements

Time documentationAnesthesia services performed, including exact time spent, must be documented in the anesthesia record to support billing.

Member identificationMember identifying information must be present on all pages of the record.

Provider signature and credentialsRendering practitioner must note credentials and legibly sign and date the record.

LegibilityDocumentation must be legible.

inv-14: Medical direction and supervision — requirements and steps

Medical direction — core requirementsAnesthesiologist must document performance of pre-anesthetic exam and evaluation, prescribe the anesthesia plan, and personally participate in the most demanding procedures (including induction and emergence, if applicable).

Delegation and oversightEnsure any procedures the anesthesiologist does not perform are performed by a qualified anesthetist and monitor anesthesia at frequent intervals.

Presence and availabilityRemain immediately physically present and available for immediate diagnosis and treatment of emergencies and provide indicated post-anesthesia care.

When criteria not metIf all medical direction requirements are not met, services are considered medical supervision and documentation must indicate whether the anesthesiologist was present at induction.

OpenPayer

Anesthesia Billing and Reimbursement Policy

Anesthesia Coverage and Documentation Criteria

Procedure Codes, Modifiers, Time Conversion and Caps

Provider Responsibilities and Non-Reimbursable Items

Key Definitions and Documentation Requirements