CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Anesthesia Billing and Reimbursement Policy

Defines billing, coding, documentation, modifier use, time unit calculation, reimbursement formulas, caps, credentialing and non-reimbursable anesthesia services for Neighborhood Health Plan of Rhode Island across listed products. Applies to in-network and out-of-network providers subject to benefit coverage and authorization rules.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyAnesthesia Billing and Reimbursement Policy

Policy CodePolicy N/A

Change TypeRevised (format/clarifications; caps and CRNA billing clarified)

Effective Date

Next Review Date

Key ActionBill under the rendering provider's name and NPI; submit actual start/stop times and total minutes; do not use 'incident to' billing for anesthesia.

SourceLink

POLICY UPDATE CHANGES

Epidural cap limits for 01967/01968 effective 8/1/2014 added; CRNA credentialing and billing/reimbursement requirements effective Sept/Oct 2014 clarified in 5/2014 and 6/2014 revisions.

Format changes and clarifying billing/coding information in 9/2013 and 5/2014.

9Key modifier/role codes listed

2Obstetrical code caps specified

9Non-reimbursable/included service categories

This policy summarizes Neighborhood Health Plan of Rhode Island's anesthesia billing and reimbursement rules for applicable products and applies to both in-network and out-of-network providers subject to benefit coverage and authorization rules. It covers claim submission requirements (electronic 837P and CMS-1500), required modifiers and modifier positioning, CRNA credentialing and billing/reimbursement, anesthesia time calculation and rounding, reimbursement formula and CMS base units usage, obstetrical code caps, global anesthesia inclusions and non-reimbursable items, and documentation and medical direction/supervision requirements.

Policy Metadata

Policy TitleAnesthesia Billing and Reimbursement Policy

PayerNeighborhood Health Plan of Rhode Island

Policy NumberN/A

Effective Date

Last Review2014-06

Next Review

StatusCURRENT

Scope SummaryDefines billing, coding, documentation, modifier use, time unit calculation, reimbursement formulas, caps, credentialing and non-reimbursable anesthesia services for Neighborhood Health Plan of Rhode Island across listed products. Applies to in-network and out-of-network providers subject to benefit coverage and authorization rules.

Codes and modifiers

Anesthesia CPT codes (not all-inclusive)CPT

00100-00936	Range of anesthesia CPT codes
00940-01999	Range of anesthesia CPT codes
62273	Anesthesia-related CPT code listed
99100-99150	Anesthesia-related CPT codes range

HCPCS anesthesia-related codesHCPCS

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

Modifiers required/with reimbursement impactsModifierCovered

AA	Anesthesia services personally performed by anesthesiologist; reimbursement = 100% of allowable
AD	Medical supervision by a physician, >4 concurrent anesthesia procedures; reimbursement = Max 3 base units + time units
QK	Medical direction of 2, 3, or 4 concurrent anesthesia procedures; reimbursement = 50% of allowable
QY	Medical direction of one CRNA by an anesthesiologist; reimbursement = 50% of allowable
QX	CRNA service with medical direction by a 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 - no additional reimbursement but should be submitted when appropriate
P2	Physical status modifier - no additional reimbursement but should be submitted when appropriate
P3	Physical status modifier - no additional reimbursement but should be submitted when appropriate
P4	Physical status modifier - no additional reimbursement but should be submitted when appropriate

1–10 of 12

1/2

Obstetrical anesthesia CPT codes with capsCPTCovered

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; capped at 28 units (420 minutes)
01968	Anesthesia for cesarean delivery following neuraxial labor analgesia/anesthesia; time-based add-on; capped at 4 units (60 minutes); not paid when billed alone
01969	Monitored anesthesia care; time-based add-on; not paid when billed alone

Qualifying circumstances add-on codes (should be billed when appropriate; not reimbursed separately)CPTNot Covered

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

Neighborhood uses CMS base unit values in the reimbursement formula: (Time units + Base units) x Anesthesia Conversion Factor x Modifier Adjustment. Base units are automatically calculated and paid and must not be submitted in the total minutes or units field on a claim.

Billing, documentation & denial risks

Billing Rule

Submit provider NPI and actual time

Submit actual start and stop times and total minutes on the claim; report total minutes in the appropriate EDI or CMS-1500 field. Claims must be billed under the name and NPI of the provider who actually rendered the anesthesia service. 'Incident to' billing for anesthesia is not recognized.

Submit actual start and stop times (e.g., 12:00 to 13:00)
Submit total minutes in the EDI 837P field or CMS-1500 unit field
Bill under rendering provider's name and NPI
'Incident to' billing for anesthesia is not recognized

Billing Rule

Use appropriate anesthesia modifiers in primary position

Include the appropriate anesthesia modifier in the primary modifier position to indicate personally performed, medically directed, or medically supervised services. Use the listed anesthesia modifiers and avoid invalid or misplaced modifiers to prevent denials.

AA, AD, QK, QY, QX, QZ
Missing, invalid, or wrong-position modifiers will cause claim denial

Billing Rule

Time unit calculation and rounding

Convert actual minutes to anesthesia time units using the policy rounding rules. Do not bill for 7 minutes or less.

7 minutes or less = do not bill (0 units)
8 to <23 minutes = 1 unit
23 to <38 minutes = 2 units
38 to <53 minutes = 3 units
53 to <68 minutes = 4 units
68 to <83 minutes = 5 units
83 to <98 minutes = 6 units
98 to <113 minutes = 7 units
113 to <128 minutes = 8 units

Billing Rule

CRNA credentialing and claim submission

CRNAs must be individually credentialed on the date of service to receive reimbursement and all CRNA claims must be billed using the CRNA's NPI. When services involve both a medically directing anesthesiologist and a CRNA for the same procedure, submit separate claims for each practitioner using their own NPI with the same CPT code and time on both claims.

CRNA must be credentialed on date of service to receive reimbursement
Bill CRNA services using the CRNA's NPI as rendering provider
When medically directed, submit separate claims for anesthesiologist and CRNA with same CPT and time

Documentation Required

Retain anesthesia record

Retain a complete, legible anesthesia record to support billed services. The anesthesia record must document exact times, include practitioner credentials and a legible signature, and contain patient identifying information on every page.

Document exact anesthesia start and end times in the anesthesia record
Rendering practitioner must note credentials and legibly sign and date the record
Member identifying information must be present on all pages
Maintain legible records

Denial Risk

Avoid non-reimbursable service billing

Do not bill for services that the policy lists as non-reimbursable; such claims will not be paid and pose a high denial risk.

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

Billing Rule

Multiple procedures 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 for all procedures. Duplicate services will not be reimbursed.

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

Policy changes and effective dates

8/1/2014obstetrical cap effective

Epidural cap limits applied during processing: 01967 capped at 28 units (420 minutes) and 01968 capped at 4 units (60 minutes); providers must still bill actual time.

Sept 2014CRNA credentialing effective

Neighborhood requires all CRNAs to be individually credentialed; CRNA must be credentialed on date of service to receive reimbursement.

Oct 1, 2014CRNA billing/reimbursement effectiveLatest

CRNA billing and reimbursement requirements effective: CRNA claims must be billed with CRNA's NPI; when medically directed, anesthesiologist paid 50% of allowable and CRNA paid 80% of the anesthesiologist payment; modifier reimbursement percentages (QY/QK/QX/QZ/AD) become effective.

5/2014format/clarifying changes

Format changes and clarifying billing/coding information; documentation of epidural cap limits for 01967/01968 added (cap effective 8/1/2014).

9/2013format changes

Administrative format changes and clarifications to billing/coding information.

OpenPayer

Anesthesia Billing and Reimbursement Policy

Policy summary

Claim submission & coverage criteria

Codes and modifiers

Billing, documentation & denial risks

Documentation & definitions

Policy changes and effective dates