CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Anesthesia Services Payment Policy 11.28.23

Defines payer reimbursement, billing, documentation, and coding rules for anesthesia services (general, regional, CRNA, medical direction/supervision) across Medicaid (excluding EFP), INTEGRITY, and Commercial lines.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyAnesthesia Services Payment Policy 11.28.23

Policy CodePolicy N/A

Change TypeAnnual review / clarifications

Effective Date

Next Review Date

Key ActionDocument type of anesthesia, exact time spent, procedure, practitioner credentials/signature, member identifiers, discontinuous time, relief provider times, and post-op pain management details on the anesthesia record.

SourceLink

POLICY UPDATE CHANGES

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

01/01/2023 Policy review: Format change, removed General Billing Information, added General Documentation Requirements.

6/1/2014 CRNA credentialing and billing/reimbursement requirements effective fall 2014.

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

8/1/2011 Policy effective date.

1Policy area (Anesthesia)

2Obstetrical code caps specified

10+Key CPT/Modifier codes listed

Policy overview

This policy defines payer-specific payment methodology for anesthesia services using CMS base unit values and an anesthesia conversion factor: reimbursement is calculated as (Total Time Units + Base Unit) x Anesthesia Conversion Factor, with a modifier adjustment applied per the provider role (for personally performed services with AA or QZ modifiers the formula includes a modifier adjustment; for medical direction modifiers QK/QX/QY the per‑provider allowance is computed similarly and then adjusted). The policy lists modifier-based payment percentages for anesthesiologists and CRNAs (for example, AA = 100%, AD = 100%, QK/QY = 50%, QX = 80% of remaining allowable, QZ = 80%) and follows CMS rules that base units are automatically calculated (do not submit base units on the claim). Applicable lines of business include Medicaid (excluding EFP), INTEGRITY, and Commercial. Operational guidance for billing and clinical documentation emphasizes billing claims under the rendering provider's name/NPI, documenting exact anesthesia start/end times and required medical direction documentation when claiming directed services, and that duplicate or excluded services (e.g., anesthesia assistants, students, salaried facility CRNAs, standby, or post‑op pain management same day as surgery) may be denied.

Medical necessity & coverage criteria

Medical Necessity Prerequisites

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

Service is medically necessary
Medical necessity may be determined using National Coverage Determination (NCD), Local Coverage Determination (LCD), industry accepted criteria such as InterQual, Rhode Island EOHHS recommendations, and Neighborhood Clinical Medical Policies
Provider must verify eligibility, coverage and authorization criteria prior to rendering services

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Reimbursable Anesthesia Services

Neighborhood will reimburse covered, medically necessary anesthesia services when performed by qualified providers and billed appropriately:

Qualified Providers: Anesthesia services performed by qualified and licensed medical doctor or certified registered nurse anesthetist (CRNA)
Relation to Covered Procedures: Services performed in conjunction with covered authorized surgical procedures
Billing Under Rendering Provider NPI: 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)

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Exclusions (Not Reimbursed)

Services that are excluded from reimbursement:

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

Payment calculation, caps, and multiple-service rules

Anesthesia Payment Calculation

Anesthesia claims are paid based on the following formulae:

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Obstetrical Anesthesia Caps

Reimbursement for specific obstetrical anesthesia codes is capped regardless of billed time; providers must continue to bill actual time and cap is applied during processing:

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

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Multiple/Duplicate Anesthesia on Same Day

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

Submit highest base-unit service only: Submit only the highest base-unit value service with the total time spent for all procedures
Duplicate services not reimbursed: Duplicate services will not be reimbursed

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Codes and modifiers

Anesthesia CPT range and related codes (Covered when billed appropriately)CPTCovered

00100-01999	Anesthesia Services
62273	Injection, epidural, of blood or clot patch
99100	Anesthesia for patient of extreme age; list separately
99116	Anesthesia complicated by utilization of total body hypothermia
99135	Anesthesia complicated by utilization of controlled hypotension
99140	Anesthesia complicated by emergency conditions
99151	Moderate sedation services initial 15 minutes, patient younger than 5
99152	Moderate sedation services initial 15 minutes, patient age 5 or older
99153	Moderate sedation services each additional 15 minutes
99155	Moderate sedation services initial 15 minutes by other qualified professional, patient younger than 5

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Anesthesia Modifiers and Payment Adjustment PercentagesModifier

AA	Anesthesia services performed personally by anesthesiologist; reimbursed 100%
AD	Medical supervision by a physician: >4 concurrent anesthesia procedures; reimbursed 100%
QK	Medical direction of 2-4 concurrent anesthesia procedures; reimbursed 50%
QY	Medical direction of one CRNA by 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	Patient with mild systemic disease; no effect on reimbursement
P3	Patient with severe systemic disease; no effect on reimbursement
P4	Patient with severe systemic disease that is a constant threat to life; no effect on reimbursement

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Documentation, billing rules, denial risks, and prior authorization

Documentation Required

Anesthesia record requirements

Document type of anesthesia, exact time spent, procedure performed matching the operative report, practitioner credentials/signature, member identifying information on all pages, patient positioning, discontinuous time, relief provider times, and post-op pain management details (surgeon request, start/stop times, block location and type). Documentation must be legible and support billed services.

Type of anesthesia performed
Exact time spent performing anesthesia services
Procedure performed matching the operative report
Rendering practitioner credentials and signature
Member identifying information on all pages
Patient positioning
Discontinuous time and relief provider times
Post-operative pain management details (surgeon request, start/stop times, block location/type)

Documentation Required

Medical direction documentation

For medical direction, document all seven required services in the patient's anesthesia record for each procedure.

Pre-anesthetic examination and evaluation
Prescribe the anesthesia plan
Personally participate in the most demanding procedures of the plan including induction and emergence, if applicable
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

Medical Direction Documentation Requirements

For each anesthesia procedure when billed as medical direction, the anesthesiologist must document ALL seven services:

1: 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 in the plan not performed by him/her are performed by a qualified anesthetist

Documentation Required

Medical supervision documentation

When an anesthesiologist does not fulfill all medical direction requirements, services are considered medical supervision services. Documentation must indicate if the anesthesiologist was present at induction; Neighborhood may request medical records to support the service billed.

Indicate that services are medical supervision when medical direction requirements are not met
Document whether the anesthesiologist was present at induction

Billing Rule

Provider and NPI billing 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 under the rendering provider's name/NPI.

Bill claims under rendering provider's name and NPI
'Incident to' billing for anesthesia is not recognized

Billing Rule

Do not submit base units

Do not submit base unit values in the total minutes or units field on a claim. Neighborhood uses CMS base unit values and base units are automatically calculated and paid during reimbursement.

Do not submit base unit values in total minutes/units field
Base units are automatically calculated and paid using CMS values

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 service with the highest base-unit value and include the total time spent for all procedures. Duplicate services will not be reimbursed.

Submit only the highest base-unit service with total time for all procedures
Duplicate services will not be reimbursed

Billing Rule

Obstetrical time cap enforcement

Providers must bill actual time for codes 01967 and 01968; Neighborhood will apply processing caps regardless of billed time. The caps are applied during claim processing.

01967
01968
01967 capped at maximum 28 units / 420 minutes
01968 capped at maximum 4 units / 60 minutes
Bill actual time; caps enforced during processing

Denial Risk

Excluded services denial risk

Claims for services billed by anesthesia assistants, students, CRNA salaried facility employees, post-operative pain management on the same day as surgery, anesthesia by the operating surgeon, anesthesia stand by, anesthesia for procedures not designated as requiring anesthesia, or anesthesia for non-covered surgical procedures may be denied.

Anesthesia assistants
Students
CRNA salaried facility employees
Post-operative pain management same day as surgery
Anesthesia by operating surgeon
Anesthesia stand by
Anesthesia for procedures not designated as requiring anesthesia
Anesthesia for non-covered surgical procedures

Prior Authorization

Out-of-network authorization

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

Separate authorization may be required for out-of-network providers billing separately
Verify plan-specific prior authorization requirements

OpenPayer

Anesthesia Services Payment Policy 11.28.23

Policy overview

Medical necessity & coverage criteria

Payment calculation, caps, and multiple-service rules

Codes and modifiers

Documentation, billing rules, denial risks, and prior authorization

Definitions

Policy changes & review timeline