CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Anesthesia_Billing_And_Reimbursement_Policy

Billing and reimbursement rules for anesthesia services to Neighborhood Health Plan of Rhode Island members across multiple products, including claim submission formats, required modifiers, reimbursement calculations, time unit rounding, caps for specified obstetrical codes, CRNA credentialing and payment splits, bundled/non-reimbursable items, and documentation requirements.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyAnesthesia_Billing_And_Reimbursement_Policy

Policy CodePolicy N/A

Change TypeRevised (multiple revisions; material items in 5/2014 and 6/2014)

Effective Date8/2011 (original); caps effective 8/1/2014; CRNA rules effective Sept/Oct 2014

Next Review Date

Key ActionProviders must submit total anesthesia time in minutes and actual start/stop times on claims and bill under the NPI of the provider who actually rendered the service.

SourceLink

POLICY UPDATE CHANGES

Epidural cap limits for 01967/01968 effective 8/1/2014 added; CRNA credentialing and reimbursement requirements effective late 2014 clarified.

Format and clarifying billing and coding information updated in multiple revisions.

2Obstetrical codes with caps

6Key anesthesia modifiers listed

8Non-reimbursable categories

Policy overview

This policy defines Neighborhood Health Plan of Rhode Island's anesthesia billing and payment rules for in-network and out-of-network providers across specified products (including Rite-Care, Rhody Health Options, Medicaid Expansion and the Health Benefit Exchange). It uses CMS conventions for base units and conversion factors and specifies claim submission formats (EDI 837P and CMS-1500), required reporting of total anesthesia minutes and actual start/stop times, provider NPI billing rules, and documentation requirements. This policy replaces prior local practices such as 'incident to' billing by requiring claims be submitted under the rendering provider's name and NPI and consolidates Neighborhood's anesthesia rules into a single guidance for provider education and adjudication.

Top-level thresholds and metadata

Vaginal delivery cap (01967)28 units / 420 minutes

Cesarean delivery add-on cap (01968)4 units / 60 minutes

Policy last review2014-06

Effective / Next reviewEffective date not specified / Next review not specified

Scope summaryBilling and reimbursement rules for anesthesia services to Neighborhood Health Plan of Rhode Island members across multiple products, including claim submission formats, required modifiers, reimbursement calculations, time unit rounding, caps for specified obstetrical codes, CRNA credentialing and payment splits, bundled/non-reimbursable items, and documentation requirements.

Claim, modifier, time and reimbursement criteria

Claim submission and provider identity

Claims must reflect the actual rendering provider and include total anesthesia time; 'incident to' billing is not recognized:

ALL of the following

Submit total time in minutes in EDI 837P format or in the unit field on CMS-1500 for paper claims
Submit actual start and stop time (e.g., 12:00 to 13:00) on the claim form above the anesthesia CPT code field
All anesthesia claims must be billed under the name and NPI of the provider who actually rendered the service; 'incident to' billing is not recognized
Providers should render services based on the scope of their particular license

Modifier and modifier placement requirements

Claims will deny when modifier rules are not followed:

ALL of the following

Modifier must be billed with anesthesia procedure codes to indicate personally performed, medically directed or medically supervised services
Claims will deny when billed without appropriate modifier for provider's specialty
Claims will deny when modifier is not billed in the appropriate modifier position
Incorrect modifier combinations (Do not file on same claim line with):
- AA - Do not file with AD, QY, QK, QX, or QZ

Anesthesia reimbursement calculation

Neighborhood pays anesthesia claims using CMS base units and conversion factors with modifier adjustments:

ANY of the following

Personally performed by anesthesiologist or CRNA (AA or QZ): (Total Time Units + Base Unit) x Anesthesia Conversion Factor x Modifier Adjustment = Allowance
Uses CMS base unit values; base units auto-calculated
Performed under medical direction (QK, QX, QY): [(Total Time Units + Base Unit) x Anesthesia Conversion Factor] x Modifier Adjustment = Allowance for each provider
See modifier adjustment percentages in Required Modifiers

Time unit calculation and rounding

Submit time units based on 15-minute intervals with specified rounding thresholds and do not bill for base units in the minutes field:

ALL of the following

Submit 1 unit for every 15-minute interval
Round up to the next unit for 8 to 14 minutes; round down for 1 to 7 minutes
Billing table
- <=7: 7 minutes or less = Do not bill<= 7 minutes
- 8-22: 8 minutes to <23 minutes = 1 unit

Obstetrical anesthesia caps

Effective 8/1/2014 caps applied during processing even if billed for actual time:

ALL of the following

Vaginal delivery cap (01967): Vaginal delivery code 01967 is capped at a maximum of 28 units (420 minutes)28 units / 420 minutes
Provider must continue to bill actual time; cap applied during processing
Cesarean delivery add-on cap (01968): Cesarean section delivery add-on code 01968 is capped at a maximum of 4 units (60 minutes)4 units / 60 minutes
Provider must continue to bill actual time; cap applied during processing
Processing note: Providers must continue to bill actual time; Neighborhood will apply the cap during processing

Multiple/duplicate anesthesia services same day

When multiple anesthesia services are administered on the same date:

ALL of the following

Submit only the highest base-unit value service with the total time spent for all procedures
Duplicate services will not be reimbursed

CRNA credentialing and billing/payment splits

CRNAs must be individually credentialed and claims for medically directed/supervised services follow separate claim rules and payment splits:

ALL of the following

Credentialing and billing: All CRNAs must be individually credentialed to receive reimbursement; effective 10/1/2014 CRNA credentialing required
Claims must be billed using CRNA's NPI as rendering provider
Claim submission: All claims must be billed using the CRNA's NPI as rendering provider to receive payment
When CRNA and medically directing anesthesiologist provide services for same procedure (single CRNA)
- Submit separate claims for each practitioner using their NPI

Physical status and qualifying circumstance modifiers

Modifiers to be submitted when appropriate; no additional reimbursement for physical status modifiers; qualifying circumstance add-ons not reimbursed separately but should be billed:

ALL of the following

Physical status modifiers P1-P6 should be submitted when appropriate; no additional reimbursement will be made
List P1-P6
Qualifying circumstance add-on codes (not reimbursed separately but should be billed when appropriate):
- 99100 - Anesthesia for Patient of Extreme Age, Under 1 Year and Over 70
- 99116 - Anesthesia Complicated By Utilization of Total Body Hypothermia
- 99135 - Anesthesia Complicated By Utilization of Controlled Hypotension

Services included in global anesthesia care (not reimbursed separately)

Items that are considered included and not separately reimbursable:

ANY of the following

Anesthesia integral to the surgical procedure
Evaluation and management for post-op pain management or routine pre- or postop anesthesia service
Post-operative pain management on the same day as surgical procedure
Maintenance of open airway and ventilator measurements and monitoring
Monitoring of EKGs, pulse breathing, blood pressure, EEG and other neurological monitoring

Non-reimbursable services

Services that will not be reimbursed:

ANY of the following

Services billed by anesthesia assistants
Services provided by students
CRNA services performed by salaried facility employees
Post-operative pain management on the same day as surgical procedure
Anesthesia by the operating surgeon
Anesthesia stand by

Medical direction and supervision documentation requirements

Required elements to document to support medical direction or medical supervision:

ALL of the following

Medical direction required elements: For medical direction, anesthesiologist must document the seven services: pre-anesthetic exam/eval; prescribe anesthesia plan; personally participate in most demanding procedures including induction/emergence if applicable; ensure procedures not performed by them are performed by qualified anesthetist; monitor course of anesthesia at frequent intervals; remain immediately physically present and available for emergencies; provide indicated post-anesthesia care
Each must be recorded in the patient's anesthesia record
Medical supervision: If anesthesiologist does not fulfill all seven services, the service is considered medical supervision; documentation must indicate if anesthesiologist was present at induction
General documentation: exact time spent performing anesthesia, practitioner credentials and signature, member identifying information on all pages, legible documentation

Codes and modifiers

Anesthesia CPT ranges and specific codesCPT

00100-00936	Anesthesia CPT code range included (not all-inclusive list)
00940-01999	Anesthesia CPT code range included (not all-inclusive list)
62273	Included anesthesia-related CPT code
99100-99150	Anesthesia qualifying/add-on CPT codes range
01960	Anesthesia for vaginal delivery only (time based)
01961	Anesthesia for cesarean delivery only (time based)
01967	Neuraxial labor analgesia/anesthesia for planned vaginal delivery (time based) - capped at 28 units
01968	Anesthesia for cesarean delivery following neuraxial labor anesthesia (time based add-on) - capped at 4 units; not paid when billed alone
01969	Monitored anesthesia care (time based add-on) - not paid when billed alone

HCPCS D-codes (oral surgery)HCPCS

D9220	Anesthesia-related D-code covered for oral surgery
D9221	Anesthesia-related D-code covered for oral surgery

Anesthesia modifiers with reimbursement impactsModifier

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 (effective 10/1/2014 DOS)
QK	Medical direction of 2,3, or 4 concurrent anesthesia procedures; reimbursement = 50% of allowable (effective 10/1/2014 DOS)
QY	Medical direction of one CRNA by an anesthesiologist; reimbursement = 50% of allowable (effective 10/1/2014 DOS)
QX	CRNA service with medical direction by physician; reimbursement = 80% of the payment made for the QK or QY claim (effective 10/1/2014 DOS)
QZ	CRNA service without medical direction by anesthesiologist; reimbursement = 80% of allowable (effective 10/1/2014 DOS)

Qualifying circumstance add-on CPTsCPT

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

Key modifier reimbursement impacts and effective dates: Neighborhood requires anesthesia modifiers (AA, AD, QK, QY, QX, QZ) on anesthesia procedure codes and applies specific payment adjustments effective for dates of service on or after 10/01/2014 — AD (medical supervision >4 concurrent) reimbursed as max 3 base units + time units; QK and QY (medical direction) reimbursed at 50% of allowable; QX and QZ (CRNA services) reimbursed at 80% of the applicable anesthesiologist payment or allowable as specified. Modifier combinations that are invalid (e.g., AA with QK/QY/QX/QZ/AD) will cause denials and CRNA credentialing and separate billing/payment splits are effective 10/01/2014.

Billing, documentation, and operational actions

Billing Rule

Submit total minutes and start/stop times

Submit total minutes and exact start and stop times on the claim. For electronic (837P) submissions, place total time in minutes in the appropriate field. For paper (CMS-1500) submissions, place total minutes in the unit field and record actual start and stop times (e.g., 12:00 to 13:00) on the claim form above the anesthesia CPT code.

Billing Rule

Bill under rendering provider's NPI

All 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.

Denial Risk

Modifier position and invalid combinations — denial risk

Place anesthesia modifiers in the correct modifier position and avoid invalid combinations. Claims will deny when modifiers are omitted, positioned incorrectly, or submitted in prohibited combinations (for example, AA must not be filed on the same claim line with AD, QY, QK, QX, or QZ; similarly QY, QK, AD, QX, and QZ have specific mutually exclusive pairings). Review the modifier grid and ensure only permitted modifier combinations are billed to avoid denial risk.

Do not file AA with AD, QY, QK, QX, or QZ on the same claim line.
Do not file QY with AA, AD, QK, QX, or QZ on the same claim line.
Do not file QK with AA, AD, QY, QX, or QZ on the same claim line.
Do not file AD with AA, QY, QK, QX, or QZ on the same claim line.
Do not file QX with AA, AD, QY, QK, or QZ on the same claim line.
Do not file QZ with AA, AD, QY, QK, or QX on the same claim line.

Billing Rule

Time unit rounding and submission

Time units must be reported using 15-minute intervals: 1 unit per 15 minutes. Round as follows: do not bill for 7 minutes or less; 8–22 minutes = 1 unit; 23–37 = 2 units; 38–52 = 3 units; etc. Submit rounded time units in the time/units field — do not submit base unit values in the minutes/units field. Base units are calculated separately and should not be entered as minutes or units on the claim.

7 minutes or less = do not bill
8 to <23 minutes = 1 unit
23 to <38 minutes = 2 units
Do not submit base units in the minutes/units field

Prior Authorization

Out-of-network authorization may be required

Out-of-network anesthesia providers may require prior authorization or separate authorization when billing separately. Verify authorization requirements before rendering services to avoid payment delays.

Documentation Required

Medical direction documentation — seven required elements

Medical direction documentation must include all required elements for services billed with directing modifiers. Maintain documentation of the seven required elements for medical direction (e.g., name of anesthesiologist, name of each CRNA directed, concurrent case details, patient identification, date/time, description of directions provided, and signatures/credentials). Keep these readily available for audit.

Document the anesthesiologist's name and credentials
Document each CRNA's name and credentials
Document which cases were concurrently directed and number of concurrent procedures
Record patient identifiers and date of service
Record exact start and stop times
Describe directions provided to CRNA(s) during the procedure
Include signature and credentials of the directing anesthesiologist

Documentation Required

General anesthesia record requirements

The general anesthesia record must be complete, legible, and include exact anesthesia start and end times, patient identifiers, provider credentials and signatures, and any other required clinical details. Time entries must support billed minutes/units.

Exact anesthesia start and end times
Provider name, credentials, and signature
Member identifiers (name, DOB, MRN)
Legible, contemporaneous entries that support billed time and services

Billing Rule

CRNA credentialing and separate claims

CRNAs must be individually credentialed with Neighborhood effective 10/1/2014 to receive reimbursement. When both a CRNA and an anesthesiologist participate, submit separate claims for each practitioner using their respective NPIs, include the same CPT code and time on both claims, and apply the appropriate modifiers per the policy (QY/QX or QK/QX combinations). Payment split rules apply (e.g., medically directed shares and CRNA percentage adjustments).

CRNA credentialing required on date of service (effective 10/1/2014)
Submit separate claims under each practitioner's NPI
Include same CPT and time on both claims
Use appropriate modifiers: QY (medical direction of one CRNA) with QX on CRNA claim; QK (medical direction of 2–4) with QX on CRNA claim

Billing Rule

Multiple anesthesia services same day

When multiple anesthesia services are provided to the same patient on the same date, submit only the service with the highest base-unit value and report the total time spent across procedures. Duplicate services or separate billing for multiple anesthesia base units on the same date will be denied.

Submit only the highest base-unit service with total time for all procedures on that date
Duplicate anesthesia services on the same date of service will not be reimbursed

Key definitions

Definitions

Base unitCMS-assigned base unit value for an anesthesia procedure; base units are automatically calculated and paid by Neighborhood and should not be submitted in the minutes/units field.

Modifier AdjustmentPercentage or payment factor applied based on the anesthesia modifier (AA, QK, QY, QX, QZ, AD) as specified in policy.

Policy revision timeline

5/2014revised

5/2014 noted epidural caps and 6/2014 added CRNA credentialing (effective Sept 2014) and CRNA billing/reimbursement (effective Oct 2014).

8/1/2014revised_detail

Epidural cap limits for 01967/01968 effective 8/1/2014 added; CRNA credentialing and reimbursement requirements effective late 2014 clarified.

9/2013revised

9/2013 and 5/2014 included format changes and clarifications; disclaimer updated.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyAnesthesia_Billing_And_Reimbursement_Policy

Policy CodePolicy N/A

Change TypeRevised (multiple revisions; material items in 5/2014 and 6/2014)

Effective Date8/2011 (original); caps effective 8/1/2014; CRNA rules effective Sept/Oct 2014

Next Review Date

Key ActionProviders must submit total anesthesia time in minutes and actual start/stop times on claims and bill under the NPI of the provider who actually rendered the service.

SourceLink

On This Page

QY - Do not file with AA, AD, QK, QX, or QZ

QK - Do not file with AA, AD, QY, QX, or QZ

AD - Do not file with AA, QY, QK, QX, or QZ

QX - Do not file with AA, AD, QY, QK, or QZ

QZ - Do not file with AA, AD, QY, QK, or QX

All other modifiers do not affect reimbursement and should not be billed in the primary modifier position; claims will deny if not billed appropriately

23-37: 23 minutes to <38 minutes = 2 units>= 23 to <38 minutes

38-52: 38 minutes to <53 minutes = 3 units>= 38 to <53 minutes

53-67: 53 minutes to <68 minutes = 4 units>= 53 to <68 minutes

68-82: 68 minutes to <83 minutes = 5 units>= 68 to <83 minutes

83-97: 83 minutes to <98 minutes = 6 units>= 83 to <98 minutes

98-112: 98 minutes to <113 minutes = 7 units>= 98 to <113 minutes

113-127: 113 minutes to <128 minutes = 8 units>= 113 to <128 minutes

Do not submit base unit values in the total minutes or units field on a claim; base units are automatically calculated and paid

Submit the same CPT procedure code and time on both claims

Add QY modifier to anesthesiologist's claim (Medical direction of one CRNA)

Add QX modifier to CRNA's claim (CRNA service with medical direction by physician)

Payment split: Payment: anesthesiologist receives 50% of allowable; CRNA receives 80% of the anesthesiologist's payment

Example: $100 allowable -> anesthesiologist $50 -> CRNA $40

When anesthesiologist medically directs/supervises >1 CRNA (2-4 concurrent)

Submit separate claims for each practitioner using their NPI
Submit the same CPT procedure code and time on both claims
Add QK modifier to supervising anesthesiologist's claim (Medical direction of 2,3, or 4 concurrent anesthesia procedures)
Add QX modifier to each medically directed CRNA's claim
Payment split: Payment: anesthesiologist receives 50% of allowable; CRNA receives 80% of the anesthesiologist's payment

99140 - Anesthesia Complicated By Emergency Conditions

Monitoring of left ventricular or valve function via TEE

Monitoring of intravascular fluids, blood administration and fluids used during cold cardioplegia through non-invasive means

Anesthetic or analgesic administration

Local anesthesia during surgery

Anesthesia for procedures not designated as requiring anesthesia

Anesthesia for non-covered surgical procedures