Policy Title: Anesthesia Services Payment Policy (Neighborhood Health Plan of Rhode Island). Payer: Neighborhood Health Plan of Rhode Island. Scope: Applies to Medicaid excluding Extended Family Planning (EFP), INTEGRITY, and Commercial lines of business.
High-level summary: Neighborhood reimburses covered, medically necessary anesthesia services (general, regional, CRNA, medical direction/supervision) performed in conjunction with covered authorized surgical procedures when rendered by qualified, licensed providers. Medical necessity may be determined using NCDs, LCDs, InterQual, EOHHS recommendations, and Neighborhood Clinical Medical Policies; providers must verify eligibility and authorization prior to services.
Calculation methodology: Neighborhood follows CMS anesthesia methodology using CMS base unit values. Reimbursement is calculated as: for personally performed anesthesia (AA or QZ) (Total Time Units + Base Unit) x Anesthesia Conversion Factor x Modifier Adjustment; for medically directed services (QK, QX, QY) [(Total Time Units + Base Unit) x Anesthesia Conversion Factor] x Modifier Adjustment. Anesthesia start time is the time the anesthesiologist begins patient preparation and end time is when the patient is placed under post-operative care. Time when the anesthesiologist is not in personal attendance is non-billable. Do not submit base unit values in the total minutes/units field; base units are auto-calculated.
Modifier-specific reimbursement percentages: AA and AD reimbursed at 100%; QK and QY medical direction reimbursed at 50%; QX (CRNA with medical direction) reimbursed at 80% of remaining allowable; QZ (CRNA without medical direction) reimbursed at 80%. ASA physical status modifiers P1–P6 have no effect on reimbursement.
Documentation expectations: Providers must document type of anesthesia, exact time spent (anesthesia record), procedure matching surgeon's operative report, rendering practitioner credentials with legible signature and date, member identifiers on all pages, patient positioning, discontinuous time, relief provider times, and specifics for post-op pain management (surgeon request, start/stop times, block location/type). For billing medical direction, the anesthesiologist must document all seven required elements (pre-anesthetic exam, anesthesia plan, personal participation in most demanding portions including induction/emergence if applicable, ensuring qualified anesthetist performs delegated tasks, frequent monitoring, immediate physical presence for emergencies, and provision of post-anesthesia care). If medical direction requirements are not met the service is considered medical supervision and documentation must indicate presence at induction. Neighborhood may request medical records and apply audits/denials if documentation or medical necessity is not supported.
Excluded services and global care: Services considered part of global anesthesia care and not reimbursed separately include anesthesia integral to the surgical procedure, routine pre/post-op anesthesia E/M or post-op pain management the same day, airway/ventilator management, monitoring (EKG, pulse, blood pressure, EEG, TEE, intravascular fluids/blood), anesthetic/analgesic administration, and local anesthesia during surgery. Explicit exclusions: services billed by anesthesia assistants, students, CRNA services by salaried facility employees, anesthesia by the operating surgeon, anesthesia standby, anesthesia for procedures not designated as requiring anesthesia, and anesthesia for non-covered surgical procedures.
Special processing rules: When multiple anesthesia services are provided the provider must submit only the single service with the highest base-unit value and include the total time spent for all procedures; duplicate services will not be reimbursed. Obstetrical caps are applied during processing though providers must bill actual time: code 01967 capped at 28 units / 420 minutes; code 01968 capped at 4 units / 60 minutes.
Billing rules and claims: 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. Coding must follow CPT, ICD-10-CM, and HCPCS standards. Claim payments remain subject to member eligibility, benefit coverage, prior authorization, contractual terms, edits, and state/federal regulations.
Policy metadata and history: Document type = reimbursement_rule. Last reviewed 11/28/2023 (annual review; modifier usage clarified). Notable prior revisions include CRNA credentialing/billing clarifications (2014) and obstetrical epidural cap introduction effective 8/1/2014.