CurrentOscar HealthPolicy N/A

Anesthesia

Defines Oscar Health reimbursement methodology, coding, modifiers, bundled services, supervision/direction rules, physical status modifiers, qualifying circumstance codes, obstetric anesthesia caps, and billing constraints for anesthesia services.

Policy Summary

PayerOscar Health

PolicyAnesthesia

Policy CodePolicy N/A

Change TypeRevised (05/29/2025); Administrative update (10/01/2025)

Effective DateDec 1, 2025

Next Review Date

Key ActionCalculate reimbursement using (Base Value + Time Units + Modifying Units) x Conversion Factor; compute time units in 15-minute intervals rounded to nearest decimal and report anesthesia start/end per policy

SourceLink

POLICY UPDATE CHANGES

10/01/2025 off-cycle verbiage update: Added "unless otherwise specified by state" to payment descriptions and to Obstetric Anesthesia section.

05/29/2025 policy update: Added sections for Supervision vs. Direction, Physical Status Modifiers, Qualifying Circumstances, Multiple Anesthesia Services, Peroperative/Postoperative Visits, Transesophageal Echocardiography, Bundled Services, and Non-Timed Services; added Related Policies and References.

4Qualifying Circumstance Codes Not Separately Reimbursable

3Add-on Anesthesia Codes (exceptions)

7Medical direction documentation requirements

Obstetric caps (cesarean, vaginal)

Policy summary and scope

Oscar aligns with CMS NCCI, ASA guidelines, and the CMS National Physician Fee Schedule for anesthesia reimbursement and coding. The policy scope covers the reimbursement methodology (using Base Value + Time Units + Modifying Units) x Conversion Factor with time calculated in 15‑minute intervals rounded to the nearest decimal), bundling rules and integral services, modifier/payment rules and supervision vs. direction requirements, qualifying circumstance codes that are bundled, and obstetric/TEE special rules. Effective date: 12/01/2025; Last review: 10/01/2025.

Policy Metadata

Effective Date2025-12-01

Last Review2025-10-01

Next Review

Policy StatusCURRENT

SubjectAnesthesia reimbursement and billing rules

Scope SummaryDefines Oscar Health reimbursement methodology, coding, modifiers, bundled services, supervision/direction rules, physical status modifiers, qualifying circumstance codes, obstetric anesthesia caps, and billing constraints for anesthesia services.

Anesthesia coverage & reimbursement rules

Anesthesia Reimbursement Formula

Oscar reimburses anesthesia when billed with appropriate base units, time units, modifying units, and conversion factor:

Calculate reimbursement using: (Base Value + Time Units + Modifying Units) x Conversion Factor

Base values defined by the American Society of Anesthesiologists (ASA)

Time units calculated on 15-minute interval basis and rounded to nearest decimal (e.g., 32 minutes = 2.1 time units)15-minute intervals; 32 minutes = 2.1 time units

Conversion factors per provider contract or CMS locality

Code lists and bundling categories

Anesthesia Modifiers (payment rules)Modifier

AA	Anesthesia services performed personally by an anesthesiologist; Payment = 100% of fee schedule based on appropriate unit rate unless otherwise specified by state
AD	Medical supervision for more than four concurrent anesthesia procedures; Payment = Reimbursed at rate equal to three base value units unless otherwise specified by state
GC	Services performed in part by a resident under direction of a teaching physician; Reimbursable at 100% when billed by teaching anesthesiologist (AAT in first field and GC certification modifier required)
QK	Medical direction of two, three or four concurrent anesthetic procedures involving qualified individuals; Payment = 50% of fee schedule payment unless otherwise specified by state
QX	CRNA performed services under the medical direction of an anesthesiologist; Payment = 50% of fee schedule payment unless otherwise specified by state
QS	Anesthesiologist medically directed one CRNA; Payment = 50% of fee schedule payment unless otherwise specified by state
CRNA (unnamed)	CRNA performed services without medical direction; Payment = 100% of fee schedule based on appropriate unit rate unless otherwise specified by state

Qualifying circumstance CPT codes (e.g., 99100, 99116, 99135, 99140) are bundled into the primary anesthesia code and are not separately reimbursable; add-on anesthesia codes (e.g., 01953, 01968, 01969) are exceptions to the single‑anesthesia‑code reporting rule and may be reported in addition per the Multiple Procedures guidance.

Billing, documentation & modifier actions

Billing Rule

Use anesthesia formula and time calculation

Calculate reimbursement using the standard anesthesia formula and compute time units on 15-minute intervals, rounded to the nearest decimal.

Time unit calculation: 15-minute intervals; 32 minutes = 2.1 time units

Billing Rule

Report single highest base unit anesthesia code for multiple procedures

When multiple surgical procedures occur during one anesthesia administration, report only the single anesthesia code with the highest base unit value and report the combined total anesthesia time for all procedures. Add-on anesthesia codes are exceptions and may be reported in addition to the primary single anesthesia code.

01953
01968

Key terms

Definitions

Base ValueASA-defined base units assigned to anesthesia procedures reflecting complexity.

Time UnitsUnits calculated in 15-minute intervals representing anesthesia duration, rounded to nearest decimal.

Modifying UnitsAdditional units applied for physical status modifiers or qualifying circumstances as applicable.

Timing rules and obstetric caps

Thresholds

Time unit calculation15-minute intervals; 32 minutes = 2.1 time units (rounded to nearest decimal)

Cesarean section capCapped at 270 minutes / 18 time units

Vaginal delivery capCapped at 225 minutes / 15 time units

Neuraxial/epidural labor analgesia is reimbursed using the standard anesthesia formula (Base Value + Time Units + Modifying Units) x Conversion Factor with actual time units subject to obstetric caps: cesarean codes capped at 270 minutes / 18 time units and vaginal delivery codes capped at 225 minutes / 15 time units.

Regulatory alignment & guidance

Oscar follows CMS National Correct Coding Initiative and Physician Fee Schedule guidance: CMS and ASA guidance drive bundling decisions and modifier/payment interpretations, and the CMS guidance cited in the policy is used to determine which codes are bundled, which modifiers affect payment, and when separate reimbursement may be considered (for example, TEE with a formal diagnostic report).

Policy changes & timeline

05/29/2025revisedLatest

Structural and content enrichment to clarify anesthesia billing and bundling rules

10/01/2025revised

Administrative wording change clarifying state-specific exceptions for payment modifiers and obstetric caps.

Policy Summary

PayerOscar Health

PolicyAnesthesia

Policy CodePolicy N/A

Change TypeRevised (05/29/2025); Administrative update (10/01/2025)

Effective DateDec 1, 2025

Next Review Date

SourceLink

On This Page

Anesthesia time definition:

Anesthesia time starts when the anesthesiologist begins to prepare the patient for induction and ends when patient can safely be placed under postoperative supervision

Medical Direction vs Medical Supervision Requirements

To bill medical direction (up to four concurrent CRNAs), ALL of the following seven requirements must be met and documented:

Medical direction requirements

Perform a pre-anesthetic examination and evaluation
Prescribe the anesthesia plan
Personally participate in the most demanding procedures in the anesthesia plan, including induction and emergence
Ensure qualified individual performs any procedures in the anesthesia plan that the anesthesiologist does not personally perform
Monitor the course of anesthesia administration at frequent intervals
Remain physically present for all key and critical portions of the procedure and be available for immediate diagnosis and treatment of emergencies
Provide post-anesthesia care as indicated

Medical supervision: Applies when a physician is overseeing more than four CRNAs concurrently; no hands-on care requirement — physician must be available to assist in any concurrent cases

Physical Status Modifiers and Modifying Units

Physical status modifiers (ASA) and their modifying units:

P1: normal healthy patient0 modifying units

P2: patient with mild systemic disease0 modifying units

P3: patient with severe systemic disease1 modifying unit

P4: patient with severe systemic disease that is a constant threat to life2 modifying units

P5: moribund patient not expected to survive without the operation3 modifying units

P6: declared brain-dead patient whose organs are being removed for donor purposes0 modifying units

Qualifying Circumstances (Not Separately Reimbursable)

Oscar follows CMS: qualifying circumstance codes are bundled and not eligible for separate reimbursement:

99100: Anesthesia for patient of extreme age (<1 year or >70 years) — not reimbursable separately

These codes are assigned status indicator 'B' on CMS fee schedule and are bundled

99116: Anesthesia complicated by utilization of total body hypothermia — not reimbursable separately

99135: Anesthesia complicated by utilization of controlled hypotension — not reimbursable separately

99140: Anesthesia complicated by emergency conditions (specify) — not reimbursable separately

Multiple Procedures During Single Anesthesia

When multiple surgical procedures occur during one anesthesia administration:

Single code rule: Report only the single anesthesia code with the highest Base Unit Value

Time reporting: Report combined total anesthesia time for all procedures on same patient/date by same or different physician or other QHP

Add-on code exceptions: Add-on anesthesia codes (01953, 01968, 01969) are exceptions and may be reported in addition

Preoperative/Postoperative E/M Services

E/M services by same specialty provider on same date as anesthesia are not separately reimbursed (CMS-consistent):

E/M not separately reimbursed: CPT codes 99091, 99202-99499 (excluding 99291-99292), and 92004-92014 when reported by Same Specialty Physician or Other QHP on same date as anesthesia will not be reimbursed separately

Transesophageal Echocardiography (TEE)

TEE is bundled with anesthesia unless performed for diagnostic purposes with formal report:

Bundled TEE: TEE placement and interpretation not separately reimbursable in addition to primary anesthesia procedure

Diagnostic TEE exception: If TEE is performed for diagnostic purposes with documentation including a formal report, it may be considered for separate reimbursement per CMS guidelines

Submit formal report to consider separate reimbursement

Bundled Services

Anesthesia CPT/HCPCS codes include numerous integral services and Oscar aligns with NCCI bundling:

Monitoring devices: Placement of external monitoring devices (cardiac monitoring, oximetry, capnography, temperature, EEG, BSER, Doppler)

Transport/positioning/prep: Transporting, positioning, prepping, draping the patient for anesthesia induction/procedure

IV placement: Placement of peripheral IV lines for fluids/medication

Airway placement: Placement of airway (endotracheal/orotracheal tube) and laryngoscopy for airway placement

NG/OG tube: Placement of nasogastric or orogastric tube

Lab interpretation: Interpretation of laboratory determinations by anesthesiologist/CRNA

Intra-op monitoring interpretation: Intra-operative interpretation of monitored functions (BP, HR, respirations, oximetry, capnography, temperature, EEG, BSER, Doppler, CNS pressure)

Nerve stimulation to determine level of paralysis/localization of nerves (EMG codes require complete diagnostic report)

Urinary catheter: Insertion of urinary bladder catheter

Blood sample procurement through existing lines or venipuncture/arterial puncture

Obstetric/Neuraxial Labor Analgesia

Reimbursement based on actual time units with caps for labor and cesarean/vaginal delivery codes:

Labor analgesia formula: Reimburse neuraxial/epidural labor analgesia using Standard Anesthesia Formula (Base Value + Time Units + Modifying Units) x Conversion Factor

Cesarean cap: Cesarean section delivery codes are capped at 270 minutes / 18 time units270 minutes / 18 time units

Unless otherwise specified by state

Vaginal delivery cap: Vaginal delivery codes are capped at 225 minutes / 15 time units225 minutes / 15 time units

Unless otherwise specified by state

Non-Timed Services

Certain CPT codes are not considered time-based anesthesia services:

01953: CPT 01953 is not considered a time-based anesthesia service per ASA guidance

01953 is also listed as an add-on exception in multiple procedures guidance

01996: CPT 01996 is not considered a time-based anesthesia service per ASA guidance

Documentation Required

Document medical direction requirements

To bill medical direction, document that all seven required elements are met in the medical record: perform a pre-anesthetic exam/evaluation; prescribe the anesthesia plan; personally participate in the most demanding procedures including induction and emergence; ensure qualified individual performs any procedures the anesthesiologist does not personally perform; monitor the course of anesthesia at frequent intervals; remain physically present for all key and critical portions and be available for immediate diagnosis and treatment of emergencies; provide post-anesthesia care as indicated.

Perform a pre-anesthetic examination and evaluation
Prescribe the anesthesia plan
Personally participate in the most demanding procedures, including induction and emergence
Ensure qualified individual performs procedures the anesthesiologist does not personally perform
Monitor the course of anesthesia administration at frequent intervals
Remain physically present for all key and critical portions and be available for immediate diagnosis and treatment of emergencies
Provide post-anesthesia care as indicated

Billing Rule

Modifiers affect payment percentage

Apply the appropriate anesthesia modifiers to indicate who provided or directed services; the modifier determines payment percentage or unit allowance and includes state-specific exceptions unless otherwise specified by state.

AA — Payment = 100% of fee schedule based on appropriate unit rate (unless otherwise specified by state)
AD — Reimbursed at rate equal to three base value units (unless otherwise specified by state)
GC — Reimbursable at 100% when billed by teaching anesthesiologist with required modifiers (unless otherwise specified by state)
QK — Payment = 50% of fee schedule payment (unless otherwise specified by state)
QS — Payment = 50% of fee schedule payment (unless otherwise specified by state)
QX — Payment = 50% of fee schedule payment (unless otherwise specified by state)
CRNA (no modifier name) — CRNA performed services without medical direction; Payment = 100% of fee schedule (unless otherwise specified by state)

Billing Rule

Do not bill qualifying circumstance codes separately

Oscar follows CMS bundling: qualifying circumstance CPT codes are included in the primary anesthesia payment and are not separately reimbursable.

99100
99116
99135
99140

Billing Rule

Do not separately bill E/M services by same specialty same date

Consistent with CMS, E/M services reported by the same specialty provider on the same date as an anesthesia service are not separately reimbursable (critical care 99291-99292 are excluded from this non-reimbursement rule).

99091
99202-99499 (exclude 99291-99292)
92004-92014

Documentation Required

TEE separate payment requires formal report

Transesophageal echocardiography (TEE) placement and interpretation is generally bundled with the primary anesthesia procedure; if TEE is performed for diagnostic purposes and a formal report is present in the medical record, submit the formal report and it may be considered for separate reimbursement per CMS guidance.