ModifiedNeighborhood Health Plan of Rhode IslandPolicy N/A

Anesthesia Services Payment Policy

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

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyAnesthesia Services Payment Policy

Policy CodePolicy N/A

Change TypeModifier, exclusions, documentation and format updates (multiple revisions)

Effective Date

Next Review Date

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

SourceLink

POLICY UPDATE CHANGES

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

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

01/01/2023 Policy review. Format change. Removed General Billing Information. Added language for General Documentation Requirements.

6/1/2014 CRNA credentialing and billing/reimbursement requirements effective Sept/Oct 2014; clarifying billing and coding information.

5/1/2014 Epidural cap limits for 01967/01968 effective 8/1/2014; format change.

11/07/2025 Annual Policy Review Date. No content changes.

1Anesthesia CPT range covered (broad group)

2Obstetrical codes with time caps

Medical direction documentation required steps

8Required anesthesia modifiers listed

Policy Summary & Scope

Payer: Neighborhood Health Plan of Rhode Island (applies to Medicaid excluding Extended Family Planning (EFP), INTEGRITY, and Commercial lines).

High-level scope: reimbursement rules for anesthesia services (including general and regional anesthesia, supplementation of local anesthesia, and supportive anesthesia services) when medically necessary and performed by qualified/licensed anesthesiologists or CRNAs; defines covered CPT anesthesia ranges and related codes, included global anesthesia care items not reimbursed separately, exclusions, documentation and billing requirements.

Purpose and calculation overview: reimbursement is calculated using Time units + Base units x Anesthesia Conversion Factor; Neighborhood uses CMS base unit values and base units are auto-calculated (do not submit base units in the total minutes/units field). Payment examples for personally performed and medically directed services are specified with modifier adjustments applied.

Key operational rules: providers must bill under the rendering provider's name and NPI (no 'incident to' billing); when multiple anesthesia services occur same day submit only the highest base-unit service with total time for all procedures; obstetrical anesthesia codes 01967 and 01968 are subject to maximum time-unit caps (claims must still reflect actual billed time and Neighborhood will apply caps during processing).

Status and review dates: MODIFIED; most recent annual review noted 11/07/2025 (Annual Policy Review Date. No content changes.) with prior material updates on 12/11/2024 (modifier tables and anesthesia exclusions updated).

PayerNeighborhood Health Plan of Rhode Island

PolicyAnesthesia Services Payment Policy

Policy NumberN/A

StatusMODIFIED

Last review2025-11-07

Effective date

Scope summaryDefines Neighborhood Health Plan of Rhode Island reimbursement, billing, documentation, modifier usage, included/excluded services, and coding rules for anesthesia services across Medicaid (excluding EFP), INTEGRITY, and Commercial lines.

Coverage Criteria & Exclusions

General Eligibility for Reimbursement

Anesthesia services are reimbursed when ALL of the following are met:

ALL of the following

Service is a covered, medically necessary anesthesia service
Service is performed in conjunction with a covered authorized surgical procedure
Service is performed by a qualified and licensed medical doctor or certified registered nurse anesthetist (CRNA)
Provider has verified member eligibility, coverage and authorization criteria prior to rendering services

Global Anesthesia Care (Not Reimbursed Separately)

Codes & Modifiers

Anesthesia CPT Range (primary covered codes)CPTCovered

00100-01999

Anesthesia services

Specific Procedure/Related CodesCPTCovered

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 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; each additional 15 minutes intraservice time (List separately in addition to code for primary service)
99155	Moderate sedation services by physician or qualified health care professional other than performing physician; initial 15 minutes; patient younger than 5 years
99156	Moderate sedation services by physician or qualified professional other than performing physician; 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 (Relative Weight Units Added)Modifier

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

Provider Billing Rules and Payment Calculation

Billing Rule

Anesthesia payment calculation

Allowance = (Total Time Units + Base Units) x Conversion Factor x Modifier Adjustment. Neighborhood uses CMS base unit values which are auto-calculated; do not submit base units in the total minutes/units field on a claim.

Billing Rule

Multiple same-day anesthesia billing

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

Documentation Requirements & Denial Risks

Documentation Required

Anesthesia time and service documentation

Document the following in the anesthesia record to support billing: type of anesthesia; exact time spent (start and end times); procedure performed matching the operative report; rendering practitioner credentials and signature; member identifying information on all pages; patient positioning; any discontinuous time; relief anesthesia provider arrival/departure times; and post‑operative pain management details (requests, start/stop times, block location and type).

Documentation Required

Medical direction documentation

To support medical direction modifiers, the anesthesiologist must document ALL seven required services in the anesthesia record: 1) pre‑anesthetic exam and evaluation; 2) prescribed anesthesia plan; 3) personal participation in the most demanding procedures (including induction/emergence if applicable); 4) assurance that tasks not performed by the anesthesiologist were performed by a qualified anesthetist; 5) monitoring at frequent intervals; 6) remaining immediately physically present and available for emergencies; and 7) providing indicated post‑anesthesia care.

Terms & Timing Definitions

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

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

Policy Revision Timeline

05/01/2014revised

2014-05-01: Format change; clarified billing and coding information; introduced epidural cap limits for 01967/01968 effective 08/01/2014. (is_material: true)

06/01/2014revised

2014-06-01: CRNA credentialing requirements effective Sept 2014 and CRNA billing/reimbursement requirements effective Oct 2014; clarified billing and coding information. (is_material: true)

01/01/2023revised

2023-01-01: Policy review with format change; removed General Billing Information and added General Documentation Requirements. (is_material: true)

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyAnesthesia Services Payment Policy

Policy CodePolicy N/A

Change TypeModifier, exclusions, documentation and format updates (multiple revisions)

Effective Date

Next Review Date

SourceLink

On This Page

The following are included in global anesthesia care and are NOT reimbursed separately:

ANY of the following

Anesthesia that is integral to the surgical procedure
Evaluation and management for post op pain management or routine pre or postop anesthesia service
Post-operative pain management on the same day as surgical procedure
Maintenance of open airway and ventilator measurements and monitoring
Monitoring of electrocardiograms (EKGs), pulse breathing, blood pressure, electroencephalogram and other neurological monitoring
Monitoring via transesophageal echocardiogram (TEE)
Monitoring of intravascular fluids, blood administration and fluids used during cold cardioplegia through non-invasive means
Anesthetic or analgesic administration
Local anesthesia during surgery

Exclusions (Not Reimbursed)

Neighborhood does not reimburse the following anesthesia-related services:

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 surgical procedure
Anesthesia by the operating surgeon
Anesthesia stand by
Anesthesia for procedures not designated as requiring anesthesia
Examples: simple wound suturing, minor skin biopsies, injections (epurals/facets/SI joints), venipuncture, certain minor office procedures like ear irrigation, removal of foreign objects from the skin, basic X-rays or ultrasounds
Anesthesia for non-covered surgical procedures

Billing Rule

Obstetrical code capping

Codes 01967 and 01968: providers must bill the actual time rendered; Neighborhood will apply caps during processing. Thresholds applied: 01967 capped at maximum 28 time units (420 minutes); 01968 capped at maximum 4 time units (60 minutes).

Obstetrical Anesthesia Capping Rules

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

ALL of the following

01967 cap: 01967 (vaginal delivery) capped at maximum 28 units / 420 minutesmaximum 28 units / 420 minutes
Provider must still bill actual time; cap applied during processing.
01968 cap: 01968 (cesarean section delivery add-on) capped at maximum 4 units / 60 minutesmaximum 4 units / 60 minutes
Provider must still bill actual time; cap applied during processing.

When multiple anesthesia services are administered to 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

Billing Rule

Billing provider NPI requirement

All 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 by Neighborhood; bill only under the rendering provider and within scope of their license.

Prior Authorization

Prior authorization verification

Verify member eligibility, coverage and any required prior authorization before rendering services. Refer to the plan-specific Prior Authorization Reference page for details. Note: out-of-network providers may require separate authorization when billing separately.

Anesthesia Personal/Direction/Medical Supervision Documentation Requirements

Documentation must support billed anesthesia service level; for medical direction, ALL seven listed services must be documented by the anesthesiologist:

ALL of the following

A pre-anesthetic examination and evaluation documented
Prescribed anesthesia plan documented
Personal participation in most demanding procedures of the anesthesia plan (including induction/emergence if applicable) documented
Assurance that procedures not performed by anesthesiologist are performed by qualified anesthetist documented
Monitoring of anesthesia course at frequent intervals documented
Anesthesiologist remained immediately physically present and available for emergencies documented
Indicated post-anesthesia care provided and documented

Provider must bill actual time and Neighborhood will apply any applicable caps or processing adjustments; documentation must record exact time spent performing anesthesia services

Denial Risk

Denial for services lacking documentation or non-covered services

Neighborhood may request medical records and may deny claims if documentation does not support the billed service level or medical necessity. Records requests, denials for insufficient documentation, and denials for excluded or non‑covered service types (for example services billed by anesthesia assistants, students, CRNA salaried facility employees, anesthesia by the operating surgeon, anesthesia stand‑by, or anesthesia for non‑required procedures) are possible outcomes when documentation is lacking or services are excluded.

Potential for medical records request to support billed services
Denial when documentation does not support billed service level or medical necessity
Explicit excluded service types (e.g., anesthesia assistants, students, CRNA salaried facility employees, anesthesia by operating surgeon, anesthesia stand‑by, non‑required procedures)

11/28/2023clarified

2023-11-28: Annual Policy Review — clarified requirements regarding modifier usage. (is_material: true)

12/11/2024revised

2024-12-11: Annual Policy Review — updated modifier tables and updated anesthesia exclusions. (is_material: true)

11/07/2025revisedLatest

2025-11-07: Annual Policy Review — No content changes. (is_material: false)