CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Anesthesia Services Payment Policy 01.01.23

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

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyAnesthesia Services Payment Policy 01.01.23

Policy CodePolicy N/A

Change TypeAdministrative, operational and format revisions (most recent review 01/01/2023)

Effective DateAug 1, 2011

Next Review Date

Key ActionDo not submit base unit values in the total minutes or units field; report actual anesthesia start and end times; base units are calculated by Neighborhood and included automatically in reimbursement.

SourceLink

POLICY UPDATE CHANGES

01/01/2023: Policy review with format change; removed General Billing Information; added language for General Documentation Requirements.

6/1/2014: CRNA credentialing requirements effective September 2014; CRNA billing and reimbursement requirements effective October 2014; clarifying billing and coding information.

5/1/2014: Format change, clarifying billing and coding information; Epidural cap limits for 01967/01968 effective 8/1/2014; Disclaimer updated.

9/1/2013: Format change only.

8/1/2011: Effective Date

2Obstetrical anesthesia codes with caps

8Explicit exclusions listed

Anesthesia-related CPT/modifier codes referenced

Policy overview

This Neighborhood Health Plan reimbursement policy covers anesthesia services for Medicaid (excluding EFP), INTEGRITY, and Commercial members and is intended for billing and clinical operations teams. The policy defines anesthesia services (including general, regional, supplementation of local anesthesia and other supportive services), references anesthesia CPT ranges and specific codes, and lists applicable modifiers and payment percentages. Reimbursement is calculated using Total Time Units + Base Units multiplied by the Anesthesia Conversion Factor (with modifier adjustments as specified), with Neighborhood using CMS base unit values and instructing providers not to submit base unit values on claims. The policy includes detailed documentation and medical direction requirements (the seven required medical direction elements and medical supervision rules), coding guidance, caps on obstetrical anesthesia codes (01967 capped at 28 units / 420 minutes and 01968 capped at 4 units / 60 minutes), exclusions (e.g., services billed by anesthesia assistants, student-provided services, CRNA services by salaried facility employees, post-operative pain management same day, anesthesia by operating surgeon, stand-by, procedures not designated as requiring anesthesia, and anesthesia for non-covered procedures), and operational/billing rules (submit only highest base-unit service when multiple anesthesia services same day, bill under rendering provider NPI—incident-to billing not recognized, and timely filing requirements).

Policy metadata

Effective Date2011-08-01

Last Review2023-01-01

Next Review

PayerNeighborhood Health Plan of Rhode Island

Policy TitleAnesthesia Services Payment Policy

Policy NumberN/A

Scope SummaryDefines reimbursement, billing, documentation, coding, caps and exclusions for anesthesia services for Neighborhood Health Plan of Rhode Island across Medicaid (excluding EFP), INTEGRITY, and Commercial lines.

Coverage & medical necessity criteria

Medical necessity prerequisite

Covered when ANY of the following sources are used to determine medical necessity:

National Coverage Determination (NCD)

Local Coverage Determination (LCD)

Industry accepted criteria such as InterQual

Rhode Island Executive Office of Health and Human Services (EOHHS) recommendations

Clinical Medical Policies (CMP)

Reimbursable anesthesia services

Covered when ALL of the following are met:

Billing, coding, and payment calculation rules

Anesthesia payment calculation

Anesthesia claims are paid based on the following formulae:

Payment formula branch

Personally performed formula: Anesthesia personally performed by anesthesiologist or CRNA (AA or QZ Modifier): (Total Time Units + Base Unit) x Anesthesia Conversion Factor x Modifier Adjustment = Allowance
Medical direction formula: Anesthesia performed under medical direction (QK, QX and QY modifiers): [(Total Time Units + Base Unit) x Anesthesia Conversion Factor] x Modifier Adjustment = Allowance for each provider

Operational rules

CMS base units: Neighborhood uses CMS base unit values

Billing, documentation & administrative actions

Billing Rule

Time reporting and base units

Do not submit base unit values in the total minutes or units field on a claim; report actual anesthesia start and end times. Base units are automatically calculated by Neighborhood and included in reimbursement.

report actual anesthesia start and end times
do not submit base units in total minutes/units field

Billing Rule

Multiple same-day services billing

When multiple anesthesia services are administered on the same patient on the same date of service, submit only the highest base-unit value service with the total time spent for all procedures. Duplicate services will not be reimbursed.

Key definitions

Definitions

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

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

Quantitative caps and thresholds

Thresholds / caps

01967 cap28 units / 420 minutes

01968 cap4 units / 60 minutes

Billing noteProviders must bill actual time; Neighborhood will apply the cap during processing.

Document changes & timeline

2011-08-01added

Effective Date

2013-09-01format change

Format change only

2014-05-01material

Format change with clarifying billing and coding information; introduced epidural cap limits for codes 01967 and 01968 effective 2014-08-01; Disclaimer updated.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyAnesthesia Services Payment Policy 01.01.23

Policy CodePolicy N/A

Change TypeAdministrative, operational and format revisions (most recent review 01/01/2023)

Effective DateAug 1, 2011

Next Review Date

SourceLink

On This Page

ALL of the following

Service is performed by a qualified and licensed provider (anesthesiologist or certified registered nurse anesthetist [CRNA])
Service is performed in conjunction with a covered, authorized surgical or procedural service

Exclusions (not reimbursed)

Not reimbursed when ANY of the following apply:

ANY of the following

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

Medical supervision documentation

Documentation must meet the following medical supervision requirements in addition to general documentation standards to support billing and the level of service reported:

ALL of the following

Record whether the anesthesiologist was present at induction when the anesthesiologist did not perform full medical direction
Document presence or absence of the seven medical direction activities when medical direction is billed: pre-anesthetic exam and evaluation; prescribing the anesthesia plan; personal participation in most demanding procedures (including induction/emergence when applicable); ensuring procedures not performed by the anesthesiologist are performed by a qualified anesthetist; monitoring anesthesia administration at frequent intervals; remaining immediately physically present and available for emergencies; providing indicated post-anesthesia care
When services are billed as medical supervision (not full medical direction), indicate which medical direction requirements were not fulfilled and document supervisory activities provided
All anesthesia records must include type of anesthesia, exact time spent (start/end and discontinuous intervals), relief provider times, procedure performed matching the operative report, practitioner credentials with legible signature and date, member identifiers on all pages, patient positioning, post-op pain management details (surgeon request, start/stop times, block location, type of regional anesthetic), and legible documentation
Neighborhood reserves the right to request medical records; documentation must support services billed and medical necessity; Neighborhood follows CMS standards for proper documentation

Do not submit base units: Do not submit base unit values in the total minutes or units field on a claim; base units are automatically calculated

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

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

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

Obstetrical anesthesia caps

Reimbursement for the following codes will be capped at the listed time units regardless of billed time; providers must still bill actual time and Neighborhood will apply the cap during processing:

01967 cap: 01967 (vaginal delivery) capped at maximum of 28 units or 420 minutes28 units / 420 minutes
Providers must bill actual time; cap applied during processing
01968 cap: 01968 (cesarean section delivery add-on) capped at maximum of 4 units or 60 minutes4 units / 60 minutes
Providers must bill actual time; cap applied during processing

Multiple/duplicate anesthesia services same day

Multiple/duplicate same day

Submit highest base-unit: Submit only the highest base-unit value service with the total time spent for all procedures when multiple anesthesia services are administered on the same patient on the same date of service
Duplicate not reimbursed: Duplicate services will not be reimbursed

Anesthesia CPT range and specific anesthesia codesCPTCovered

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 initial 15 minutes, patient younger than 5 years (list separately in addition to code for primary anesthesia procedure)
99152	Moderate sedation services initial 15 minutes, patient age 5 years or older (list separately in addition to code for primary anesthesia procedure)
99153	Moderate sedation services each additional 15 minutes intraservice time (list separately in addition to code for primary service)
99155	Moderate sedation initial 15 minutes, other clinician, patient younger than 5 years

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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%
P1	Normal healthy patient; no effect on reimbursement
P2	A patient with mild systemic disease; no effect on reimbursement
P3	A patient with severe systemic disease; no effect on reimbursement
P4	A patient with severe systemic disease that is a constant threat to life; no effect on reimbursement

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Prior Authorization

Out-of-network provider authorization

Out-of-network providers may require separate authorization when billing separately; verify plan-specific prior authorization requirements prior to rendering services.

Documentation Required

General anesthesia documentation requirements

Document the following to support anesthesia billing and medical necessity:

type of anesthesia
exact time spent performing anesthesia services
procedure performed matching the operative report
practitioner credentials, legible signature and date
member identifying information on all pages
patient positioning
discontinuous time
relief anesthesia provider times (when each leaves or comes on)
post-operative pain management details (surgeon request, start/stop times, block location, type of regional anesthetic/peripheral nerve block)
legible records

Documentation Required

Medical direction documentation

To support billing under medical direction modifiers, the anesthesiologist must document the seven specified medical direction services in the patient's anesthesia record for each procedure.

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 not performed by the anesthesiologist 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

Denial Risk

Incident-to and incorrect billing risk

Incident-to billing for anesthesia services is not recognized by Neighborhood. Claims must be billed under the name and NPI of the provider who actually rendered the service or risk denial.

Documentation Required

Neighborhood record requests

Neighborhood reserves the right to request medical records for any billed service. Documentation in the medical record must support the services billed and the medical necessity of those services.

Billing Rule

Timely filing

Providers are required to submit complete claims for payment within contractually determined timely filing guidelines.

2014-06-01material

CRNA credentialing requirements effective September 2014; CRNA billing and reimbursement requirements effective October 2014; clarifying billing and coding information.

2023-01-01non-materialLatest

Policy review with format change; removed General Billing Information and added language for General Documentation Requirements.