CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Anesthesia Services Payment Policy – Archive 3

Defines Neighborhood Health Plan of Rhode Island reimbursement, billing, documentation, coding, and modifier rules for anesthesia services across Medicaid (excluding EFP), INTEGRITY, and Commercial lines.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyAnesthesia Services Payment Policy – Archive 3

Policy CodePolicy N/A

Change TypeRevised (12/11/2024); Clarified (11/28/2023); Revised (01/01/2023)

Effective Date

Next Review Date

Key ActionAnesthesiologist must document the seven medical direction services in the anesthesia record for each procedure to support billing under medical direction modifiers.

SourceLink

POLICY UPDATE CHANGES

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

11/28/2023 Annual Policy Review Date: Clarified requirements regarding modifier usage.

01/01/2023 Policy review: Format change and added General Documentation Requirements.

2Obstetrical code caps

7Required medical direction elements

6Physical status modifier levels (P1-P6)

Policy Overview

This policy defines Neighborhood Health Plan of Rhode Island reimbursement, billing, documentation, coding, modifier payment percentages, and exclusions for anesthesia services across Medicaid (excluding EFP), INTEGRITY, and Commercial lines. It describes which anesthesia services are reimbursable when medically necessary and performed by qualified providers (anesthesiologists and CRNAs) and notes exclusions such as anesthesia assistants, student-provided services, CRNA services by salaried facility employees, anesthesia by the operating surgeon, standby anesthesia, post-operative pain management on the same day as the surgical procedure, and anesthesia for procedures not designated as requiring anesthesia.

Neighborhood reimburses anesthesia claims using the formula (Total Time Units + Base Unit) x Anesthesia Conversion Factor and applies modifier adjustments depending on the service and modifier. Neighborhood uses CMS base unit values and follows CMS documentation standards. Modifier payment percentages include: AA = 100%, AD = 100%, QK = 50%, QY = 50%, QX = 80% of remaining allowable, and QZ = 80%. Physical status modifiers P1–P6 and their relative weight unit additions are required where applicable.

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. Coding must follow CPT, ICD-10-CM and HCPCS standards. The policy requires that records support billed services and contain detailed anesthesia documentation (type of anesthesia, exact time spent, procedure matching surgeon's operative report, practitioner credentials/signature, patient identifiers, positioning, discontinuous time, relief provider times, and post-operative pain management details).

Policy Quick Facts

effective_date

last_review2024-12-11

next_review

policy_numberN/A

subjectAnesthesia Services Payment Policy

scope_summaryDefines Neighborhood Health Plan of Rhode Island reimbursement, billing, documentation, coding, and modifier rules for anesthesia services across Medicaid (excluding EFP), INTEGRITY, and Commercial lines.

Obstetrical code caps01967 capped at maximum 28 units (420 minutes); 01968 capped at maximum 4 units (60 minutes)

Required medical direction elementsSeven required services must be documented by the anesthesiologist (pre-anesthetic exam, prescribe plan, participate in most demanding parts including induction/emergence, ensure qualified anesthetist performs other parts, monitor frequently, remain immediately available for emergencies, provide post-anesthesia care)

Physical status modifier levelsP1–P6 defined (P1/P2 = 0 RWU added; P3 = +1; P4 = +2; P5 = +3; P6 = 0)

Coverage & Medical Necessity Criteria

Medical Necessity Prerequisites

Services must be medically necessary and Neighborhood may use the following criteria to determine medical necessity:

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

Reimbursable Anesthesia Services

Neighborhood will reimburse covered, medically necessary anesthesia services performed in conjunction with covered authorized surgical procedures when performed by qualified providers:

Qualified provider and reimbursement

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

Time definitions and billing rules

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

Obstetrical Anesthesia Caps

Reimbursement caps applied regardless of billed time; provider must still bill actual time:

01967 cap: Vaginal delivery code 01967 capped at maximum 28 units (420 minutes)28 units / 420 minutes
Provider must still bill actual time; cap applied at processing
01968 cap: Cesarean section delivery add-on code 01968 capped at maximum 4 units (60 minutes)4 units / 60 minutes
Provider must still bill actual time; cap applied at processing

Multiple/Duplicate Anesthesia Services Same Day

When multiple anesthesia services administered to same patient same date:

Multiple/Duplicate same-day rule: Submit only the highest base-unit value service with the total time spent for all procedures

Duplicate services will not be reimbursed

Excluded/Not Reimbursed Services

Services Neighborhood does not reimburse separately or excludes:

Excluded: anesthesia assistants: Anesthesia assistants (services billed by anesthesia assistants)
Excluded: students: Services provided by students
Excluded: salaried CRNA employees: CRNA services performed by salaried facility employees
Excluded: post-op pain same day: Post-operative pain management on the same day as surgical procedure
Listed as included in global anesthesia care and not reimbursed separately

Code Lists

Anesthesia CPT Range and Specific CodesCPT

00100-01999	Anesthesia Services
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 the same physician, initial 15 minutes, patient younger than 5 years
99152	Moderate sedation services provided by the same physician, initial 15 minutes, patient age 5 years or older
99153	Moderate sedation additional 15 minutes (List separately in addition to code for primary service)
99155	Moderate sedation by other qualified professional, initial 15 minutes, patient younger than 5 years

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Required Anesthesia ModifiersModifier

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 not expected to survive without operation; Relative Weight Units Added = 3
P6	Declared brain-dead patient whose organs are being removed for donor purposes; Relative Weight Units Added = 0

Billing, Documentation & Provider Impact

Documentation Required

Record required medical direction elements

Anesthesiologist must document all seven medical direction services in the anesthesia record for each procedure to support billing under medical direction modifiers.

A pre-anesthetic examination and evaluation
Prescribe the anesthesia plan
Personally participate in the most demanding procedures of the anesthesia plan including, if applicable, induction and emergence
Ensure procedures he/she does not perform are performed by a qualified anesthetist
Monitor the course of anesthesia administration at frequent intervals
Remain immediately physically present and available for immediate diagnosis and treatment of emergencies
Provide the indicated post-anesthesia care

Documentation Required

Support billed services with anesthesia record

The anesthesia record must support billed services by documenting the type of anesthesia, exact time spent, and other identifiers and clinical details to substantiate the claim.

Type of anesthesia services performed, including exact time spent
Procedure performed must match the surgeon's operative (operative report)
Rendering practitioner credentials, legible signature and date
Member identifying information on all pages
Patient positioning
Discontinuous time documented
Relief anesthesia provider times (when each provider leaves/comes on case)
Post-operative pain management details: surgeon request, start/stop times, block location, type of regional anesthetic/peripheral nerve block
Documentation must be legible

Billing Rule

Submit highest base-unit service when multiple on same day

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

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 services is not recognized.

Billing Rule

Obstetrical code caps applied at processing

Providers must bill the actual time rendered for obstetrical anesthesia codes 01967 and 01968, but Neighborhood will apply processing caps to reimburse no more than the listed maximum time units.

01967 — cap: 28 units (420 minutes)
01968 — cap: 4 units (60 minutes)

Denial Risk

Excluded services risk denial

Certain services are excluded and may be denied if billed separately; claims for these services are not reimbursed under this policy.

Services billed by anesthesia assistants
Services provided by students
CRNA services performed by salaried facility employees
Anesthesia provided by the operating surgeon
Standby anesthesia
Anesthesia for procedures not designated as requiring anesthesia (e.g., simple wound suturing, minor skin biopsies, certain injections, venipuncture, minor office procedures, some basic diagnostic procedures)
Post-operative pain management on the same day as the surgical procedure
Anesthesia for non-covered surgical procedures

Documentation Definitions & Requirements

Neighborhood bases anesthesia base unit values on Centers for Medicare and Medicaid Services (CMS) base unit values and follows CMS documentation standards for supporting billed anesthesia services. Reimbursement is calculated using time units plus base units multiplied by the anesthesia conversion factor, with modifier adjustments applied per the payer's modifier rules.

The policy distinguishes medical direction from medical supervision by specified documentation requirements. For medical direction, the anesthesiologist must document seven required services in the anesthesia record: a pre-anesthetic exam and evaluation; prescribing the anesthesia plan; personal participation in the most demanding portions of the plan (including induction and emergence if applicable); ensuring procedures not personally performed are done by a qualified anesthetist; monitoring the course of anesthesia at frequent intervals; remaining immediately physically present and available for emergencies; and providing indicated post-anesthesia care.

When the anesthesiologist does not meet all medical direction requirements, the services are considered medical supervision and documentation must at minimum indicate whether the anesthesiologist was present at induction. Neighborhood reserves the right to request medical records to verify documentation and medical necessity.

Medical Direction Documentation Requirements

For each anesthesia procedure, anesthesiologist must document the seven required services:

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 procedures he/she does not perform are performed by a qualified anesthetist
5: Monitor the course of anesthesia administration at frequent intervals
6: Remain immediately physically present and available for immediate diagnosis and treatment of emergencies
7: Provide the indicated post-anesthesia care

Medical Supervision Documentation Requirements

When anesthesiologist does not fulfill all medical direction requirements:

Medical Supervision Documentation Requirements: Services are considered medical supervision services when anesthesiologist does not fulfill all medical direction requirements

Documentation must indicate if the anesthesiologist was present at induction

General Documentation Requirements

Records must support billed services and include the following:

Type and time: Type of anesthesia services performed, including exact time spent
Procedure match: Procedure performed must match the surgeon's operative report
Credentials and signature: Rendering practitioner must note credentials, legibly sign and date the record
Member identifiers: Member identifying information present on all pages

Key Definitions

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

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

OpenPayer

Anesthesia Services Payment Policy – Archive 3

Policy Overview

Coverage & Medical Necessity Criteria

Code Lists

Billing, Documentation & Provider Impact

Documentation Definitions & Requirements

Policy Revision History