Currentpriority healthPolicy 107

Anesthesia - 107

Policy governs billing, coding, documentation, and reimbursement rules for anesthesia services (general, inhalation, regional, peripheral block, spinal, epidural, IV regional block, field block, local anesthesia), monitored anesthesia care (MAC), and moderate sedation for Priority Health; includes modifier use, time/unit reporting, qualifying circumstances, CRNA/physician direction, and payment exceptions.

Policy Summary

Payerpriority health

PolicyAnesthesia - 107

Policy CodePolicy 107

Change TypeMultiple additions and clarifications

Effective Date

Next Review DateJul 1, 2025

Key ActionProviders must maintain complete and thorough documentation to substantiate procedures performed; failure to document may result in denial or recovery of payment.

SourceLink

POLICY UPDATE CHANGES

Added 'Priority Health Medicare anesthesia billing' section

Added details to 'Post operative pain management services' section including modifier 59 and XU use, epidural and peripheral nerve block billing requirements, and same-catheter guidance

Added table under Moderate sedation billing section

1Policy Topics (Anesthesia services)

50%CRNA oversight split reimbursement

15-minuteTime unit increment

Policy summary & scope

This Priority Health anesthesia billing policy provides guidance aligned with CMS/ASA coding for anesthesia billing and reimbursement. It covers general, inhalation, regional, peripheral block, spinal, epidural, IV regional block, field block and local anesthesia services, as well as monitored anesthesia care (MAC) and moderate sedation. The policy describes use of anesthesia base units and time units measured in 15-minute increments, requirements for reporting time (report units on the claim line and actual begin/end times in box 19), and when anesthesia is payable versus included in a surgical global fee (for included services append modifier 47 to the surgical CPT). It explains modifier application (physical status modifiers, medical direction/oversight modifiers such as QK/QX/QY, resident/teaching physician GC, anesthesiologist personal performance AA, more than four concurrent procedures AD, CRNA modifiers QZ/QX, monitored anesthesia QS, and distinct procedural service modifiers like 59 or XU) and states modifiers must be supported by documentation. The policy clarifies CRNA billing and split-payment rules (CRNAs may personally perform anesthesia with QZ; when medical direction/oversight applies reimbursement is split ~50% and appropriate modifier such as QX must be appended). It details qualifying circumstance codes that are not separately reimbursed (for example 99100, 99116, 99135, 99140), rules for when epidural or peripheral nerve block injections may be billed separately for postoperative pain (allowed only in specific intraoperative anesthesia contexts and not when delivered through the same catheter with a narcotic/analgesic), limits on multiple anesthesia services per session (only the most complex service paid; add-on exceptions such as 01953, 01968, 01969), that MAC must be reported with QS and is reimbursed to a single provider per day, and that failure to follow coding, modifier, time reporting or documentation requirements may result in claim denials or recovery of payments.

Policy metadata and thresholds

Policy number107

SubjectAnesthesia services billing and reimbursement

StatusCURRENT

Last review2026-04-21

Next review2025-07-01

Effective date

Anesthesia time unit increment15-minute increments

Payable vs Not Payable & general coverage rules

Payable vs Not Payable

Anesthesia services payable only when billing rules and coverage conditions met:

ALL of the following

Payable when reported with either base units and time units or with global fees
Not payable when the procedure for which anesthesia is administered is non-covered
Not payable when physician who furnishes the medical or surgical service also performs the anesthesia service separately (anesthesia included in surgical CPT; append modifier 47 to surgical CPT instead)
Not payable for separate payment for DME and supplies to administer anesthesia when procedure reimbursed under global fees (examples: tubing, needles)

Relevant CPT/Modifier code groups

Anesthesia base/time codes and relatedCPTCovered

0XXXX	Anesthesia codes (generic reference)
00326	Reference for extreme age coding example
00561	Reference for extreme age coding example
00834	Reference for extreme age coding example
00836	Reference for extreme age coding example

Qualifying circumstances (no separate reimbursement)CPTCovered

99100	Anesthesia for patient of extreme age, younger than 1 year and older than 70
99116	Anesthesia complicated by utilization of the total body hypothermia
99135	Anesthesia complicated by utilization of controlled hypotension
99140	Anesthesia complicated by emergency conditions

Epidural / spine injection codes referencedCPTCovered

62320-62327	Epidural injection series
623XX	Epidural injection (generic family referenced for 623XX)

Peripheral nerve block codes referencedCPTCovered

64400-64530	Peripheral nerve block series
64XXX	Peripheral nerve block family (generic reference)

Modifiers required / referencedModifier

47	Modifier indicating anesthesia performed by surgeon (append to surgical CPT)
QZ	CRNA personal performance
QX	CRNA services billed with medical direction modifier
QK	Medical direction by physician (listed as appropriate modifier)
QY	Medical direction/oversight modifier
AA	Anesthesiologist performed personally
AD	More than four concurrent anesthesia procedures with medical supervision by a physician
GC	Anesthesia with resident under direction of teaching physician
59	Distinct procedural service; used for postoperative pain management when applicable
XU	Modifier for distinct procedural service (used for postop pain when applicable)

1–10 of 14

1/2

Surgery anesthesia example codes for sterilizationCPTCovered

00851	Anesthesia code for female sterilization (when sterilization only reason for encounter)
00952	Anesthesia code for female sterilization (alternate)

Billing, documentation & modifier actions

Documentation Required

Complete documentation required

Maintain complete, thorough documentation to substantiate the anesthesia services performed. Documentation should meet any additional requirements in applicable guidelines and the provider manual. Failure to document may result in claim denial or recovery of payment.

Billing Rule

Report anesthesia time units and actual times

Report anesthesia time units in 15-minute increments on the claim line (example: 1/2 hour = report two units). Also enter the actual begin and end times in claim box 19 (example: “Service began at 11:30 a.m. and ended at 1:25 p.m.”). Time reporting begins when induction is initiated (generally within a few minutes of the start of the operative session) and ends when the patient is transferred to recovery and the provider is no longer in personal attendance.

Key terms

Definitions

Monitored Anesthesia Care (MAC)Anesthesia care provided by anesthesiologist, CRNA or qualified anesthetist under medical direction; must follow CMS criteria for billing, coding, and documentation and reported with modifier QS; reimbursed only to a single provider per day.

Medicare-specific guidance

The policy notes a Medicare NCD/PSOD requirement: when indications do not meet an NCD, local LCD, or specific medical policy, a Pre-Service Organization Determination (PSOD) is required for Medicare. It also adds a distinct Priority Health Medicare anesthesia billing section: providers contracted with Priority Health Medicare products are paid per contract and should bill according to Medicare rules, while non-contracted providers are paid according to Medicare payment schedules for their geographic area. The policy records Medicare-specific updates in the change history and references Medicare coding guidance (Medicare NCCI/Coding Policy Manual) to provide payer-specific billing guidance for both contracted and non-contracted providers.

Policy changes & timeline

2026-04-21addedLatest

Added table under Moderate sedation billing section

2025-07-11added

Added 'Priority Health Medicare anesthesia billing' section; provides Medicare payer-specific billing guidance for contracted and non-contracted providers

2025-07-11revised

Added details to 'Post operative pain management services' section including modifier 59 and XU use, epidural and peripheral nerve block billing requirements, and same-catheter guidance

Policy Summary

Payerpriority health

PolicyAnesthesia - 107

Policy CodePolicy 107

Change TypeMultiple additions and clarifications

Effective Date

Next Review DateJul 1, 2025

Key ActionProviders must maintain complete and thorough documentation to substantiate procedures performed; failure to document may result in denial or recovery of payment.

SourceLink

On This Page

Multiple anesthesia services per surgical session

Rules for reporting multiple anesthesia services:

ALL of the following

Only the most complex anesthesia service should be reported per surgical session; base units calculated for primary procedure and additional anesthesia procedures will be denied
If two different providers bill duplicate anesthesia services, only the first submission of that code will be paid
Exceptions: Add-on codes 01953, 01968, 01969 may be listed in addition to primary procedure code
No additional reimbursement for unusual positioning even with modifier 22

Postoperative pain management services

Conditions when postoperative pain management billed separately by anesthesia provider:

ALL of the following

Postoperative pain management may be reported by anesthesia provider if documentation supports post-op pain management and diagnosis is linked to claim line (example G89.18)
Separate billing allowed when
- Surgeon requests anesthesia provider to manage patient's pain after recovery period is over; anesthesia provider should bill using modifier 59 or XU
- An epidural injection (CPT code 623XX) for managing postoperative pain can be billed separately with an anesthesia code (0XXXX) only if general anesthesia was used during the operation and effectiveness of anesthesia does not rely on the epidural injection
- A peripheral nerve block injection (CPT codes 64XXX) for postoperative pain can be billed separately with an anesthesia code (0XXXX) only if intraoperative anesthesia is general, subarachnoid, or epidural and its effectiveness doesn't depend on the nerve block
An epidural or peripheral nerve block injection (62320-62327 or 64400-64530) given before or during surgery cannot be billed separately for postoperative pain management if the anesthesia used is monitored anesthesia care, moderate conscious sedation, regional anesthesia by peripheral nerve block, or any other type not mentioned
An epidural or peripheral nerve block used for intraoperative pain management is covered under the 0XXXX anesthesia code and cannot be billed separately even if it also manages postoperative pain
Postoperative pain management shall not be reported with CPT 62320-62327 if a narcotic or analgesic is injected postoperatively through the same catheter as the anesthetic agent

Monitored Anesthesia Care (MAC)

Coverage and billing requirements for MAC:

ALL of the following

MAC eligible for coverage when performed by anesthesiologist, CRNA, or qualified anesthetist under medical direction of a physician
Follow CMS criteria for billing, coding, and documentation standards for MAC services
Monitored anesthesia claims must be reported with modifier QS
MAC reimbursed only to a single provider per day (anesthetist or anesthesiologist)

Moderate sedation billing rules

Rules for billing moderate sedation:

ALL of the following

Not payable when
- Moderate sedation billed by a separate anesthesiologist (Not Payable)
- Moderate sedation billed without modifier 59, XE, XP, XS or XU on same date of service as local or topical anesthesia performed by the same provider, unless provider's specialty is Anesthesiology or CRNA (Not Payable)
Moderate sedation billed by the same physician or qualified health professional who performs the service requiring sedation
When billed in addition to surgical codes, notes may be requested; refer to CPT manual for moderate sedation codes

Physician medical direction requirements

Requirements the anesthesiologist must perform and document when providing medical direction:

ALL of the following

Pre-anesthesia evaluation
Establish the anesthesia plan
Participate in induction and emergence
Oversee procedures performed are performed by qualified individuals
Oversee and frequently monitor the course of anesthesia
Be physically present for immediate emergencies to diagnose and treat
Provision of post-anesthetic care

Documentation must be complete and thorough to substantiate procedures performed; failure may result in denial or recovery of payment

Anesthesia time reporting

How to report anesthesia time units:

ALL of the following

Payment determined by CPT base value and time; time units measured in 15-minute increments
Report units on claim line (example: 1/2 hour = report two units) and actual time in box 19 with begin and end times
Reporting begins when induction is initiated (generally within a few minutes of initiation of operative session)
Reporting ends when patient transferred to recovery room and provider no longer in personal attendance

Prior Authorization

PSOD for Medicare non-covered indications

For Medicare, when an indication does not meet an NCD, local LCD, or a specific medical policy, complete a Pre‑Service Organization Determination (PSOD) prior to billing.

Billing Rule

Modifier use required and supported by documentation

Apply appropriate modifiers only when supported by documentation. Incorrect or unsupported modifier use can lead to claim denials.

Billing Rule

MAC single provider per day

Monitored anesthesia care (MAC) claims must include modifier QS. MAC reimbursement is limited to a single provider per day; only one provider (anesthetist or anesthesiologist) will be reimbursed for MAC on a given day.

Append modifier QS to MAC claims
MAC reimbursed to a single provider per day

Billing Rule

CRNA payment split when oversight required

When CRNA oversight/medical direction is required, append the appropriate modifier (e.g., QX) and payment is reimbursed as a 50% split with the supervising anesthesiologist. When a CRNA personally performs the service without medical direction, append QZ.

Append QX when medical direction/oversight applies (50% split to supervising anesthesiologist)
Append QZ when CRNA personally performs service

Denial Risk

Duplicate anesthesia claims

If two different providers submit the same anesthesia service, only the first submission of that code will be paid; duplicate submissions may be denied.

Billing Rule

Multiple anesthesia services limited

Only report the most complex anesthesia service per surgical session; base units are calculated for the primary procedure and additional anesthesia procedure lines will be denied except for specified add-on codes.

Do not report additional anesthesia services for the same session except add-on codes: 01953, 01968, 01969