CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Anesthesia Services Payment Policy 12.11.24

Defines reimbursement, billing, documentation, included and excluded anesthesia services, modifier and time/unit calculation, and coding guidance for Neighborhood Health Plan of Rhode Island for Medicaid (excluding EFP), Integrity, and Commercial lines.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyAnesthesia Services Payment Policy 12.11.24

Policy CodePolicy N/A

Change TypeRevised / Clarified (modifier tables, exclusions, documentation)

Effective Date

Next Review Date

Key ActionDocument the type of anesthesia, exact time spent, matching operative procedure, provider credentials/signature, member identifiers, positioning, discontinuous and relief provider times, and post-op pain management details to support billing.

SourceLink

POLICY UPDATE CHANGES

12/11/2024 Annual Policy Review Date; updated modifier tables and anesthesia exclusions.

11/28/2023 Annual Policy Review Date; clarified requirements regarding modifier usage.

01/01/2023 Policy review; format change and added language for General Documentation Requirements.

28/42001967 cap (max units/minutes)

4/6001968 cap (max units/minutes)

7Medical direction documentation items required

Physical status modifiers listed (P1-P6)

Policy summary

This payment policy defines anesthesia services (including general, regional, supplementation of local anesthesia and other supportive anesthesia care) and specifies who may perform them (qualified and licensed medical doctors and certified registered nurse anesthetists). Reimbursement is contingent on medical necessity and proper documentation and follows CMS anesthesia billing methodology using CMS base units plus time units multiplied by an anesthesia conversion factor, with modifier adjustments as specified.

The policy applies to Neighborhood Health Plan of Rhode Island lines: Medicaid (excluding EFP), INTEGRITY, and Commercial. Effective/last review: Last review 2024-12-11 (document history notes annual reviews and updates to modifier tables and exclusions).

Medical necessity & coverage criteria

Medical necessity prerequisite

All services must be medically necessary to qualify for reimbursement. Neighborhood may use the following sources to determine medical necessity:

ALL of the following

NCD: National Coverage Determination (NCD) applies
LCD: Local Coverage Determination (LCD) applies
Interqual: Industry accepted criteria such as Interqual may be used
RI EOHHS: Rhode Island Executive Office of Health and Human Services (EOHHS) recommendations may be used
Neighborhood CMP: Neighborhood Clinical Medical Policies (CMP) may be used

Reimbursement calculation

Anesthesia claims are paid based on time units, base units and conversion factor and modifier adjustments:

Allowance - personally performed: Allowance = (Total Time Units + Base Unit) x Anesthesia Conversion Factor x Modifier Adjustment for anesthesia personally performed by anesthesiologist or CRNA (AA or QZ modifier)

Do not submit base units in the total minutes/units field; base units are automatically calculated

Allowance - medical direction: Allowance = [(Total Time Units + Base Unit) x Anesthesia Conversion Factor] x Modifier Adjustment for anesthesia performed under medical direction (QK, QX, QY modifiers) applied for each provider

Base units: Base unit values use CMS base unit values and base units must not be submitted in the total minutes/units field (base units are automatically calculated)

Start time: Anesthesia start time = time the anesthesiologist begins preparation of the patient

Obstetrical anesthesia caps

Reimbursement for the listed obstetrical anesthesia codes is capped at the maximum time units regardless of billed time; provider must bill actual time and Neighborhood will apply the cap during processing.

01967 cap: Code 01967 (vaginal delivery) capped at maximum 28 units or 420 minutesMaximum 28 units / 420 minutes

Provider must bill actual time; Neighborhood will apply the cap during processing

01968 cap: Code 01968 (cesarean section delivery add-on) capped at maximum 4 units or 60 minutesMaximum 4 units / 60 minutes

Provider must bill actual time; Neighborhood will apply the cap during processing

Multiple/Duplicate anesthesia services same day

When multiple anesthesia services are administered to the same patient on the same date of service:

Submit highest base-unit service: Submit only the service with the highest base-unit value and include the total time spent for all procedures

Duplicate services will not be reimbursed

Duplicates not reimbursed: Duplicate services will not be reimbursed

Exclusions (Not reimbursed)

The following services are excluded from reimbursement:

Anesthesia assistants: Services billed by anesthesia assistants

Students: Services provided by students

Salaried facility CRNAs: CRNA services performed by salaried facility employees

Post-op same day: Post-operative pain management on the same day as surgical procedure

Listed as not reimbursed separately in global care

Operating surgeon:

Documentation & medical direction requirements

Medical direction documentation (requirements)

ALL of the following

1. A pre-anesthetic examination and evaluation;
2. Prescribe the anesthesia plan;
3. Personally participate in the most demanding procedures of the anesthesia plan including, if applicable, induction and emergence;
4. Ensure that any procedure in the anesthesia plan that he or she does not perform are performed by a qualified anesthetist;
5. Monitor the course of anesthesia administration at frequent intervals;

Code lists & modifiers

Anesthesia CPT range (primary anesthesia codes)CPTCovered

00100-01999

Anesthesia Services

Specific procedure/adjunct codes mentionedCPTCovered

62273	Injection, epidural, of blood or clot patch
99100	Anesthesia for patient of extreme age, younger than 1 year and older than 70 (List separately in addition to code for primary anesthesia procedure)
99116	Anesthesia complicated by utilization of total body hypothermia (List separately in addition to code for primary anesthesia procedure)
99135	Anesthesia complicated by utilization of controlled hypotension (List separately in addition to code for primary anesthesia procedure)
99140	Anesthesia complicated by emergency conditions (specify) (List separately in addition to code for primary anesthesia procedure)
99151	Moderate sedation services provided by same physician/qualified professional; initial 15 minutes, patient younger than 5 years
99152	Moderate sedation services by same physician/qualified professional; initial 15 minutes, patient age 5 years or older
99153	Moderate sedation services by same physician/qualified professional; each additional 15 minutes (List separately in addition to code for primary service)
99155	Moderate sedation by a physician/qualified professional other than treating clinician; initial 15 minutes, patient younger than 5 years
99156	Moderate sedation by a physician/qualified professional other than treating clinician; initial 15 minutes, patient age 5 years or older

1–10 of 11

1/2

Required Anesthesia Modifiers and Reimbursement PercentagesModifier

AA	Anesthesia services performed personally by anesthesiologist; reimbursed 100%
AD	Medical supervision by a physician: more than four concurrent anesthesia procedures; reimbursed 100%
QK	Medical direction of two, three or four concurrent anesthesia procedures involving qualified individuals; reimbursed 50%
QY	Medical direction of one CRNA by an anesthesiologist; reimbursed 50%
QX	CRNA service: with medical direction by a physician; reimbursed 80% of remaining allowable
QZ	CRNA service: without medical direction by a physician; reimbursed 80%

Physical Status Modifiers (P1-P6)Modifier

P1	Normal healthy patient; Relative Weight Units Added = 0
P2	Patient with mild systemic disease; Relative Weight Units Added = 0
P3	Patient with severe systemic disease; Relative Weight Units Added = 1
P4	Patient with severe systemic disease that is a constant threat to life; Relative Weight Units Added = 2
P5	Moribund patient who is not expected to survive without the operation; Relative Weight Units Added = 3
P6	Declared brain-dead patient whose organs are being removed for donor purposes; Relative Weight Units Added = 0

Key terms

Definitions

Anesthesia start timeTime the anesthesiologist begins the preparation of the patient.

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

Caps, thresholds, and special billing rules

Thresholds

01967 capMaximum 28 units / 420 minutes

01968 capMaximum 4 units / 60 minutes

Providers must bill the actual time the anesthesia service was rendered; Neighborhood will apply processing caps where specified. For obstetrical anesthesia, code 01967 (vaginal delivery) is capped at 28 units / 420 minutes and code 01968 (C‑section add‑on) is capped at 4 units / 60 minutes, but providers must still submit the actual time on the claim.

See the obstetrical criteria and general documentation requirements for supporting documentation and medical necessity rules; Neighborhood may use NCDs, LCDs, Interqual, RI EOHHS recommendations and internal CMPs to determine medical necessity. Neighborhood will apply the caps during claim processing and duplicate or multiple same‑day services are subject to the multiple/duplicate service rule.

Policy changes

12/11/2024revisedLatest

12/11/2024 Annual Policy Review Date; updated modifier tables and anesthesia exclusions.

11/28/2023clarified

11/28/2023 Annual Policy Review Date; clarified requirements regarding modifier usage.

01/01/2023revised

01/01/2023 Policy review; format change and added language for General Documentation Requirements.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyAnesthesia Services Payment Policy 12.11.24

Policy CodePolicy N/A

Change TypeRevised / Clarified (modifier tables, exclusions, documentation)

Effective Date

Next Review Date

SourceLink

On This Page

See policy definition for exact wording

End time: Anesthesia end time = time when patient is placed under post-operative care

See policy definition for exact wording

Non-billable attendance: Time anesthesiologist is not in personal attendance is non-billable

Anesthesia by the operating surgeon

Stand by: Anesthesia stand by

Not designated procedures: Anesthesia for procedures not designated as requiring anesthesia (examples: simple wound suturing, minor skin biopsies, injections such as epidurals/facets/SI joints, venipuncture, certain minor office procedures like ear irrigation, removal of foreign objects from the skin, some basic diagnostic procedures)

Non-covered procedures: Anesthesia for non-covered surgical procedures

6. Remain immediately physically present and available for immediate diagnosis and treatment of emergencies; and

7. Provide the indicated post-anesthesia care.

Medical supervision documentation

When the anesthesiologist does not meet all medical direction requirements above, the service is considered medical supervision.

Documentation must indicate if the anesthesiologist was present at induction. Services are considered medical supervision when all seven medical direction elements are not fulfilled. Records must support billed level of service and medical necessity; Neighborhood follows CMS standards for documentation.

General documentation requirements

General documentation requirements for all anesthesia services:

ALL of the following

Type of anesthesia services performed, including exact time spent performing anesthesia services (start and end times) to support billing; anesthesia start time = preparation begins, end time = placed under post-operative care.
Procedure performed — must match the surgeon's procedure as documented in the operative report.
Rendering practitioner/qualified healthcare professional must note their credentials and legibly sign and date the record.
Member identifying information must be present on all pages of the record.
Patient positioning.
Discontinuous time (periods when anesthesia care was not continuous).
Relief anesthesia providers — times when each anesthesia provider leaves or comes on to a case (relief provider times).
Post-operative pain management — surgeon request, start and stop times, location of block placement, type of regional anesthetic/peripheral nerve block and any post-op pain management details.
Documentation must be legible.

Documentation Required

Maintain complete anesthesia record

Maintain a complete anesthesia record. Ensure the anesthesia record contains the items below.

Type of anesthesia and exact start/end times (total time documented).
Procedure performed matching operative report.
Rendering provider name, credentials, dated signature.
Member identifiers on every page and patient positioning.
Discontinuous time and relief provider on/off times.
Post-op pain management details (requests, times, block location/type).
Legible, complete entries supporting billed service and medical necessity.

Denial Risk

Claims subject to audit and denial if documentation inadequate

Claims are subject to audit and may be denied if documentation is insufficient. Neighborhood reserves the right to request medical records for any service billed; documentation must support the service(s) billed and medical necessity.

Records may be requested during review or audit.
Inadequate or missing documentation can result in claim denial or recoupment.

Billing Rule

Modifier usage affects reimbursement percentage

Modifier usage affects reimbursement percentage. Apply appropriate anesthesia modifiers and ASA physical status modifiers; reimbursement varies by modifier.

Anesthesiologist personally performed: AA, QZ — standard allowance based on (Total Time + Base Unit) x Conversion Factor x Modifier Adjustment.
Medically directed: QK, QY, QX — allowance calculated per provider with Modifier Adjustment applied.
Other modifiers: AD (medical supervision by anesthesiologist), QK, QY, QX, QZ may affect payment.
Use ASA physical status modifiers P1–P6 where applicable; these may alter reimbursement percentage per policy/contract.

Billing Rule

Submit claims under rendering provider NPI

Submit claims under the rendering provider's NPI; incident-to billing is not recognized for anesthesia.

All anesthesia claims must be billed under the provider who actually rendered the service (their name and NPI).
'Incident to' billing for anesthesia services is not accepted by Neighborhood.

Billing Rule

Time and base unit submission

Time and base unit submission rules. Report total anesthesia time in minutes/units; do not submit base units in the total minutes/units field.

Submit total time units (minutes) separately; base units are not to be entered in the time/units field.
Neighborhood uses CMS base unit values and calculates base units automatically during reimbursement.

Billing Rule

Multiple same-day anesthesia services

Multiple same-day anesthesia services. 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 the total time for all procedures.

Only the highest base-unit value service should be billed with total time for all procedures.
Duplicate anesthesia services on the same date will not be reimbursed.

Billing Rule

Obstetrical code caps – apply during processing

Obstetrical anesthesia code caps — applied during processing. Neighborhood will cap time units for specific obstetrical anesthesia CPT codes; continue to bill actual time but cap will be applied in adjudication.

CPT 01967 (vaginal delivery) is capped at a maximum of 28 units (420 minutes).
CPT 01968 (cesarean section delivery add-on) is capped at a maximum of 4 units (60 minutes).
Provider must continue to bill the actual time rendered; Neighborhood applies the cap during processing.

Prior Authorization

Verify prior authorization and eligibility

Verify prior authorization and eligibility. Providers must confirm member eligibility and any plan-specific prior authorization requirements before rendering services.

Check member eligibility and benefits prior to service.
Refer to Neighborhood's plan-specific Prior Authorization Reference page for authorization requirements.