Anesthesia Policy - Commercial
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Defines Network Health Plan of Wisconsin's reimbursement rules and billing requirements for anesthesia services for the Commercial line of business, including coding, modifiers, time reporting, and bundled local anesthetic handling, affecting participating providers submitting professional claims.
No material clinical or coverage changes in this revision.
Anesthesia Reimbursement Criteria
Anesthesia reimbursement criteria
Requirements and payment rules for reimbursing anesthesia professional services.
Informational modifiers
- GC — service performed in part by a resident under direction of a teaching physician (may be appended in addition to required anesthesia delivery modifier).
- P3, P4, P5 — patient status modifiers (do not increase reimbursement).
Codes, Modifiers, and Time Units
| 99100 | Anesthesia for patient of extreme age (younger than 1 year and older than 70) |
| 99116 | Anesthesia complicated by utilization of total body hypothermia |
| 99135 | Anesthesia complicated by utilization of controlled hypotension |
| 99140 | Anesthesia complicated by emergency conditions |
| 01996 | Anesthesia code excluded from modifier requirement |
| AA | Anesthesia services performed personally by Anesthesiologist |
| AD | Medical supervision by a physician; more than four concurrent anesthesia procedures |
| QK | Medical direction of two, three, or four concurrent anesthesia procedures |
| QX | CRNA service with medical direction by a physician |
| QY | Medical direction of one CRNA by an anesthesiologist |
| QZ | CRNA service: without medical direction by a physician |
Billing Requirements and Provider Instructions
Submit required anesthesia modifiers and report anesthesia time
Append the appropriate anesthesia modifier (AA, AD, QK, QX, QY, QZ) to indicate whether the service was personally performed, medically directed, or supervised, and report total anesthesia time in minutes in box 24G; Network Health converts minutes to units at 1 unit per 15 minutes. Claims submitted without a required modifier will be denied (CARC 4).
- Include total anesthesia time in minutes in box 24G on the HCFA1500/professional claim form.
- Network Health converts minutes to units: 1 unit = 15 minutes.
- If a required anesthesia modifier is missing the claim will be denied with CARC 4.
- Anesthesia code 01996 is excluded from the modifier requirement.
- Reimbursement is 50% when services are submitted with modifiers QK, QX or QY.
Do not bill J3490/J3590 for common local anesthetics in POS 11 or 22
Do not submit HCPCS J3490 or J3590 for Lidocaine, Marcaine, or Bupivacaine in Place of Service 11 (office) or 22 (on‑campus outpatient hospital); these charges are considered bundled to the primary procedure and will be denied (CARC 97).
Anesthesia-Related Definitions
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