CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Anesthesia reimbursement/payment policy

Defines Neighborhood Health Plan of Rhode Island reimbursement rules, documentation, coding and billing requirements for anesthesia services for Medicaid (excluding EFP), Integrity, and Commercial lines of business and affects anesthesiologists and CRNAs.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyAnesthesia reimbursement/payment policy

Policy CodePolicy N/A

Change TypeRevised / Clarified

Effective DateN/A

Next Review DateN/A

Key ActionProviders must verify eligibility, coverage and authorization criteria; prior authorization may be required per plan.

SourceLink

POLICY UPDATE CHANGES

Epidural cap limits for codes 01967/01968 noted (effective 8/1/2014).

Format change. Removed General Billing Information: Added language for General Documentation Requirements Policy.

CRNA credentialing requirements and CRNA billing and reimbursement requirements updated (effective Sept/Oct 2014).

28 units / 420 min01967 cap

4 units / 60 min01968 cap

100%AA/AD reimbursement

50%QK/QY reimbursement

80%

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Anesthesia Coverage and Billing Rules

Coverage criteria and billing rules for anesthesia

Covered when ALL of the following are met:

Services must be medically necessary and performed in conjunction with a covered, authorized surgical procedure.

Services must be performed by a qualified, licensed provider (medical doctor or certified registered nurse anesthetist [CRNA]) and billed under the NPI/name of the provider who actually rendered the service; 'incident to' billing for anesthesia is not recognized.

Services must be billed in accordance with contractual timely filing requirements and meet AMA CPT, ICD-10-CM and HCPCS coding standards.

Documentation must support the service furnished, including type of anesthesia, exact start/end time (including discontinuous time and relief providers' times), provider credentials, procedure correlating with the operative report, block placement details when applicable, and legible provider signatures.

Reimbursement is calculated using CMS base units and anesthesia time: (Total time units + base units) x Anesthesia Conversion Factor x modifier adjustment allowance; modifier-specific payment adjustments apply.

Excluded services (NOT reimbursed)

Services billed by anesthesia assistants or provided by students.
CRNA services performed by salaried facility employees.
Anesthesia furnished by the operating surgeon or anesthesia stand-by services.
Anesthesia for procedures not designated as requiring anesthesia or for non-covered surgical procedures.
Post-operative management on the same day when considered part of the surgical/global anesthesia care.

Services listed as integral to global anesthesia care are not separately reimbursed (includes anesthesia integral to the procedure; routine pre/post-op E/M and post-operative pain management on the surgical day; intraoperative monitoring such as EKG, respiratory and blood pressure monitoring, EEG and other neurological monitoring; maintenance of airway and ventilator monitoring; TEE monitoring; intravascular fluid and blood monitoring via non-invasive means; anesthetic/analgesic administration; and local anesthesia during surgery).

When multiple anesthesia services are administered on the same day, submit only the service with the highest base units with the total time; duplicate services will not be reimbursed.

Obstetrical anesthesia time caps apply to specific epidural codes (e.g., 01967 and 01968) and are subject to processing caps regardless of time billed.

Modifier payment adjustments

Modifier AA and AD: 100% reimbursement of allowed anesthesia payment.
Modifier QK and QY: 50% reimbursement of allowed anesthesia payment.
Modifier QX and QZ: 80% reimbursement of allowed anesthesia payment.

Neighborhood reserves the right to audit billed services and request medical records to support medical necessity and documentation of anesthesia care.

Anesthesia Procedure Codes and Limits

Covered CPT CodesCPTCovered

00100-01999	Anesthesia services
62273	Injection, epidural, of blood or clot patch
99100	Anesthesia for patient of extreme age
99116	Anesthesia addition to code for primary anesthesia procedure
99135	Anesthesia complicated by controlled hypotension (add-on)
99140	Anesthesia complicated by emergency conditions (add-on)
99151-99157	Moderate sedation services codes and time increments

Obstetrical anesthesia time caps

01967 (vaginal delivery)Capped at a maximum of 28 time units (420 minutes); providers must bill actual time and Neighborhood will apply the cap during processing.

01968 (cesarean section add-on)Capped at a maximum of 4 time units (60 minutes); providers must bill actual time and Neighborhood will apply the cap during processing.

Billing requirementProviders must continue to bill the actual time the service was rendered even when caps apply; caps are enforced at processing.

Prior Authorization and Provider Responsibilities

Prior Authorization

Verify eligibility, coverage and prior authorization requirements

It is the provider's responsibility to verify member eligibility, coverage and any prior authorization requirements before rendering anesthesia services. Neighborhood may require prior authorization per the member's plan; providers should consult Neighborhood's Prior Authorization Reference page or Provider Services for plan-specific requirements.

Verify member eligibility and coverage prior to service delivery.
Confirm whether prior authorization is required for the planned anesthesia service per the member's plan.
Refer to Neighborhood's Prior Authorization Reference page or contact Provider Services at 1-800-963-1001 for plan-specific authorization guidance.

Key Definitions and Documentation Requirements

Anesthesia start/end time

Anesthesia start time definitionThe time the anesthesiologist begins preparation of the patient.

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

Non-billable timeTime the anesthesiologist is not in personal attendance is non-billable.

Base units handlingDo not submit base unit values in the total minutes or units field on a claim; base units are automatically calculated by Neighborhood.

Medical direction / supervision

Seven required services (must be documented)1) Pre-anesthetic exam and evaluation; 2) Prescribe the anesthesia plan; 3) Ensure procedures not performed by physician are performed by a qualified anesthetist; 4) Personally participate in the most demanding procedures of the plan (including induction and emergence, if applicable); 5) Monitor the course of anesthesia at frequent intervals; 6) Provide indicated post-anesthesia care; 7) Remain immediately physically present and available for immediate diagnosis and treatment of emergencies.