CurrentUCarePolicy UM14P0008A6

Anesthesia (Medicare)

UCare payment policy describing billing, reimbursement formulas, eligible providers, modifiers, coding guidance, and claim submission requirements for general anesthesia and monitored anesthesia care (MAC) for UCare Medicare and dually integrated products.

Policy Summary

PayerUCare

PolicyAnesthesia (Medicare)

Policy CodePolicy UM14P0008A6

Change TypeClarified / Revised (annual reviews)

Effective DateAug 1, 2014

Next Review DateN/A

Key ActionSubmit claims using MN-ITS 837-P or electronic equivalent including actual anesthesia minutes; do not submit base units (UCare will calculate allowed amount).

SourceLink

POLICY UPDATE CHANGES

March 31, 2025: Clarified language regarding dually integrated products.

March 17, 2025: Annual review complete; corrected product names in applicable products section; updates to definition and payment information for clarity.

April 19, 2024: Annual review completed; intent unchanged; wording and grammar clarified.

June 22, 2023: Annual policy review; updates to definitions, provider eligibility, and Modifiers/CPT/HCPCS/Revenue Codes sections.

3Eligible provider types listed

15Minutes per anesthesia unit

1Related payment policy referenced

Policy overview

This UCare payment policy describes how anesthesia services (general anesthesia and Monitored Anesthesia Care - MAC) are billed and reimbursed for UCare Medicare and dually integrated products. Providers should bill using the ASA/CPT anesthesia code set adopted by UCare for anesthesia (ASA codes 00100–01999) and applicable anesthesia/MAC modifiers. Reimbursement for anesthesia services uses the standard anesthesia formula: payment is based on ASA base units plus time converted to units plus the conversion factor (formula: (ASA Base Units) + (Total Time / 15 (rounded to the nearest tenth)) x Current Conversion Factor). For medically supervised services when Medicare rules apply, UCare allows three (3) base units and an additional one (1) base unit when the physician is present at induction, multiplied by the current conversion factor. Anesthesia time must be submitted as exact minutes; UCare converts minutes to units where 15 minutes = 1 unit and units are calculated to one decimal place.

Payment eligibility criteria

Enrollee Eligibility

Service eligible for payment when ALL of the following are met:

Member is actively enrolled in a UCare Medicare or UCare Dually Integrated product

Eligible Providers

Anesthesia services are eligible for payment when furnished by the following provider types:

Physician Anesthesiologist

Certified Registered Nurse Anesthetist (CRNA)

Anesthesiologist Assistant (AA)

Provider notes: Medicare's and MHCP's list of eligible providers are not the same; provider eligibility follows Medicare rules for UCare Medicare products

Monitored Anesthesia Care (MAC) Payment Eligibility

MAC is eligible for payment when ALL of the following are met:

MAC is requested by the attending physician or operating surgeon

Pre-anesthetic examination and evaluation is performed

A prescriptive anesthesia plan outlining the anesthesia care required is documented

Administration of necessary oral and parenteral medication takes place

Continuous physical presence of the anesthesiologist or qualified provider (as described) is present

Medically Directed vs Medically Supervised vs Personally Performed Definitions

Conditions that determine payment percentage and required documentation:

Personally Performed: physician personally performed the entire anesthesia service alone or meets Medicare teaching/resident criteria or is continuously involved in a single case with a student nurse anesthetist

Payment reimbursed at 100% of the allowed amount when personally performed

Medically Directed: physician medically directs qualified individuals in two, three, or four concurrent cases and performs required activities (pre-anesthetic exam, prescribes plan, participates in most demanding procedures, ensures qualified anesthetist performs delegated portions, frequent monitoring, physically present and available for emergencies, provides post-anesthesia care) and medical record documents these activities

Payment reimbursed at 50% of the allowed amount when medically directed; medical record must document listed activities

Medically Supervised: physician supervises more than four procedures concurrently or is performing other services for a significant period while directing concurrent cases

Medically supervised: allow three (3) base units, +1 base unit if physician present at induction; reimbursement per modifier grid

Thresholds

Anesthesia time unit conversion15 minutes = 1 unit; units calculated to one decimal (minutes/15 rounded to one decimal)

Time reporting requirementSubmit exact number of minutes from preparation for induction to end of personal attendance

Example conversionExample: 62 minutes / 15 = 4.1 units

Code lists & modifiers

Anesthesia code set (ASA/CPT)CPT

00100-01999

ASA anesthesia procedure codes (base units are assigned from this range)

Anesthesia Modifiers (payment impact)Modifier

AD	Medical Supervision by a physician; more than 4 concurrent anesthesia procedures; allow 3 base units, +1 base unit if physician present at induction; provider type: Anesthesiologist
QK	Medical direction of two, three or four concurrent anesthesia procedures involving qualified individuals; reimbursed at 50% of Medicare allowed amount; provider: Anesthesiologist
QX	CRNA service with medical direction by a physician; reimbursed at 50% of Medicare allowed amount; provider: CRNA/AA
QY	Medical direction of one qualified non-physician anesthetist by an anesthesiologist; reimbursed at 50% of Medicare allowed amount; provider: Anesthesiologist
G8	MAC for deep, complex, complicated, or markedly invasive surgical procedures; informational; submit actual time; must also submit personally performed or appropriate medical direction modifier
G9	MAC for patient with history of severe cardiopulmonary condition; informational; see G8
QS	MAC service modifier (can be used by physician or qualified non-physician anesthetist); see G8
AA	Anesthesia services performed personally by the anesthesiologist; reimbursed at 100% of Medicare allowed amount
QZ	CRNA service without medical direction by a physician; reimbursed at 100% of Medicare allowed amount
GC	Services performed by a resident under direction of teaching physician; reporting indicates compliance with Chapter 12 of Medicare's Claims Processing Manual; payment rules vary by circumstance

Physical Status Modifiers (informational only)Modifier

P1-P6

Physical status modifiers considered informational only and do not affect payment (includes P5: moribund patient; P6: declared brain-dead organ donor)

Related policy cross-referencemixed

SC14P0005A6

Anesthesia - MHCP (related payment policy)

Billing, documentation & submission requirements

Billing Rule

Claim submission format

Submit claims using MN-ITS 837-P format or the electronic equivalent and include the actual anesthesia minutes on the claim. Do not submit anesthesia base units on the claim — UCare will calculate the allowed amount using base units.

Billing Rule

Anesthesia time reporting

Report the exact number of anesthesia minutes from preparation for induction to the time the anesthesiologist/CRNA is no longer in personal attendance. UCare converts submitted minutes to units (15 minutes = 1 unit) and calculates units to one decimal place.

Billing Rule

Modifier reporting

Append the appropriate anesthesia and MAC modifiers as applicable. Applicable modifiers include: AD, QK, QX, QY, G8, G9, QS, AA, QZ, and GC. Note: G8, G9, and QS are informational MAC modifiers and must be submitted with the personally performed or appropriate medical direction modifier and the actual anesthesia time.

Documentation Required

Medically directed documentation

When billing as medically directed, the medical record must document that the physician performed the required medical direction activities: pre-anesthetic examination and evaluation; prescribed the anesthesia plan; personally participated in the most demanding portions (including induction/emergence if applicable); ensured delegated portions were performed by a qualified anesthetist; monitored anesthesia at frequent intervals; remained physically present and available for immediate diagnosis and treatment of emergencies; and provided indicated post-anesthesia care. If a group practice splits duties, the record must identify the physicians and which services each furnished.

Billing Rule

Reimbursement percentages

Personally performed anesthesia is reimbursed at 100% of the allowed amount. Medically directed anesthesia is reimbursed at 50% of the allowed amount. Medically supervised reimbursement follows the modifier/payment grid (see AD for specific base-unit allowances).

Prior Authorization

Prior authorization reference

Check UCare's current prior authorization, notification, and threshold requirements at the UCare prior authorization link. Authorization/notification/threshold rules may be updated periodically; providers must verify the most current requirements before submitting services that may require authorization.

Key definitions

Definitions

Anesthesiologist Assistant (AA)Masters-level individual who works under direction of an anesthesiologist and can obtain pre-anesthetic history, perform exams, establish monitors, administer medications, and execute anesthetic techniques as delegated.

Certified Registered Nurse Anesthetist (CRNA)Advanced practice registered nurse with graduate-level education and board certification in anesthesia.

Base Units or Base ValueNumber of units assigned to the ASA code (00100 - 01999).

Medically DirectedPhysician directs qualified individuals in 2-4 concurrent cases and performs specified activities (pre-anesthetic exam, prescribes plan, participates in demanding portions, oversight/monitoring, physical presence, post-anesthesia care) documented in medical record.

Medically SupervisedPhysician supervises more than four procedures concurrently or is performing other services for a significant period while directing concurrent cases.

Monitored Anesthesia Care (MAC)Intra-operative monitoring by an anesthesiologist or qualified provider under direction of an anesthesiologist including pre-anesthetic exam, prescription of anesthesia plan, medication administration, and continuous monitoring; eligible when criteria are met and performed by eligible provider.

Policy changes & review timeline

March 31, 2025clarifiedLatest

Clarified language regarding dually integrated products.

March 17, 2025revised

Annual review complete; corrected product names in applicable products section; updates to definition and payment information for clarity.

April 19, 2024revised

Annual review completed; intent unchanged; wording and grammar clarified.

June 22, 2023revised

Annual policy review; updates to definitions, provider eligibility, and Modifiers/CPT/HCPCS/Revenue Codes sections.

OpenPayer

Anesthesia (Medicare)

Policy overview

Payment eligibility criteria

Code lists & modifiers

Billing, documentation & submission requirements

Key definitions

Medicare references

Policy changes & review timeline