CurrentUCarePolicy SC14P0005A6

Anesthesia (MHCP)

UCare payment policy defining billing, provider eligibility, modifier use, time reporting, and payment calculation rules for general anesthesia, monitored anesthesia care (MAC), sedation levels, and special anesthesia services for Minnesota Health Care Programs (MHCP) products.

Policy Summary

PayerUCare

PolicyAnesthesia (MHCP)

Policy CodePolicy SC14P0005A6

Change TypeClarified / Revised (annual reviews)

Effective DateAug 14, 2014

Next Review Date

Key ActionSubmit claims using MN-ITS 837P (or electronic equivalent) with appropriate anesthesia modifier in the first modifier position and report exact anesthesia minutes.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes were made in recent reviews; updates were clarifications and formatting only.

1Applies to MHCP product family

3Eligible provider types

11Key anesthesia modifiers documented

Policy summary and scope

This policy defines UCare's billing and payment rules for anesthesia services for Minnesota Health Care Programs (MHCP) products, adopting CMS/ASA base values and MHCP rules. It covers provider eligibility (anesthesiologists, CRNAs, and limited MDs), criteria for medical direction and teaching anesthesiologists, monitored anesthesia care (MAC), levels of sedation (moderate and deep), special invasive anesthesia services, modifier-based payment calculations, time reporting, and related payment limits and documentation requirements.

Eligibility and coverage criteria

Enrollee Eligibility

To be eligible for anesthesia services the patient must meet ALL of the following:

ALL of the following

Patient is actively enrolled in a UCare Minnesota Health Care Program (MHCP) product.

Eligible Providers

Anesthesia services are eligible for payment when furnished by ONE of the following providers:

ANY of the following

Anesthesiologists (MDAs)
Certified Registered Nurse Anesthetists (CRNAs)
Physician MDs under limited conditions (see MHCP for guidance)

Criteria for Medical Direction (Anesthesiologist)

UCare will reimburse medically directed services personally performed by an anesthesiologist only when ALL of the following are met:

ALL of the following

Performs the pre-anesthetic examination and evaluation
Prescribes the anesthesia plan
Personally participates in the most demanding procedures in the anesthesia plan, including induction and emergence, if applicable
Ensures procedures they do not personally perform that are listed in the anesthesia plan are performed by a qualified individual
Monitors the course of anesthesia administration at frequent intervals

Services Furnished by a Resident (Teaching Anesthesiologist)

UCare will reimburse a teaching anesthesiologist at the personally performed rate when ALL of the following are met:

ALL of the following

Teaching anesthesiologist is involved with one anesthesia case with a resident
Teaching anesthesiologist is present during induction, emergence, and all critical portions of the procedure
Teaching anesthesiologist is immediately available during the entire service
Medical record documents the teaching anesthesiologist's presence and participation

Concurrent Direction of CRNAs

Payment limits when an anesthesiologist supervises multiple concurrent procedures:

Anesthesiologist providing medical direction must be physically present in the operating suite.

If supervising >= 5 concurrent procedures: Payment for eligible services personally performed by the anesthesiologist shall not exceed three base units and 1 unit for induction.

Surgeon Supervision Exclusion

UCare will NOT reimburse surgeon supervision for anesthesia services when supervising any of the following provider types:

Anesthesia Assistant

CRNA

Intern

Resident

Monitored Anesthesia Care (MAC) Requirements

MAC includes the following components and requirements (ALL must be met):

Pre-procedure visit

Intra-procedure care

Post-procedure anesthesia management

Continuous presence requirement: While MAC is furnished the anesthesiologist or CRNA must be physically present continuously, providing monitoring of vital signs, airway maintenance, evaluation of vital functions, diagnosis/treatment of clinical problems, administration of medications as needed, and additional services to ensure safe completion of the procedure.

Moderate Sedation (Conscious Sedation)

Moderate sedation coverage requires the following components (ALL):

Member remains conscious and able to communicate during the entire procedure

Member can independently and continuously maintain a patent airway and respond appropriately

Performance and documentation of pre-sedation and post-sedation evaluations

Administration of the sedation or analgesic agents

Monitoring of cardiorespiratory functions (pulse oximetry, cardiorespiratory monitor, and blood pressure)

Deep Sedation

Deep sedation characterization and permitted providers:

Deep sedation is a drug-induced depression of consciousness where patients cannot be easily aroused and ventilatory function may be impaired; patients may require assistance in maintaining a patent airway and spontaneous ventilation may be inadequate.

Emergency medicine physicians (MDs) whose advanced practice training has prepared them for airway management, advanced life support and rescue from any level of sedation may administer deep sedation.

Member-Controlled Analgesia (During Hospitalization)

UCare covers member-controlled analgesia under the following conditions (ALL):

Continuous infusion of pain medication facilitated by an infusion pump in a hospital setting

Medically necessary daily pain management service

Service must be conducted face to face

Special Services Covered

UCare covers specialized invasive monitoring services when performed by an anesthesiologist or independent CRNA:

Insertion of Swan-Ganz catheters

Placement of central venous lines

Placement of arterial lines

Modifiers and code groups

Anesthesia Modifiers (payment guidance)Modifier

AD	Medical Supervision by a physician; more than 4 concurrent anesthesia procedures. Additional MHCP Info = 4 base units X CF.
QK	Medical direction of two, three or four concurrent anesthesia procedures involving qualified individuals. Additional MHCP Info = (Base Units) + (Time Units) / 15 x conversion factor x 0.632.
QX	CRNA service with medical direction by a physician. Additional MHCP Info = (Base Units) + (Time Units) / 15 x conversion factor x 0.632.
QY	Anesthesiologist medically directs one CRNA. Additional MHCP Info = (Base Units) + (Time Units) / 15 x conversion factor x 0.632.
G8	Monitored anesthesia care (MAC) for deep complex, complicated, or markedly invasive surgical procedures. Informational modifier; submit personally performed or appropriate medical direction modifier with G8. Submit actual time on the claim.
G9	Monitored anesthesia care for patient with history of severe cardiopulmonary condition. See G8.
QS	Monitored anesthesia care service. Modifier must be in secondary position. See G8.
AA	Anesthesia services performed personally by the anesthesiologist. Payment = (Base Units) + (Time Units) / 15 x Conversion Factor.
QZ	CRNA service without medical direction by a physician. Payment = (Base Units) + (Time Units) / 15 x Conversion Factor.
GC	Teaching physician modifier; indicates services performed by resident or SRNA under direction of teaching anesthesiologist. AA, GC payment formula same as AA.

1–10 of 11

1/2

Physical Status Modifiers (informational only)Modifier

P1	Normal healthy patient (informational only; does not affect payment).
P2	A patient with mild systemic disease (informational only).
P3	A patient with severe systemic disease (informational only).
P4	A patient with severe systemic disease that is a constant threat to life (informational only).
P5	A moribund patient who is not expected to survive without the operation (informational only).
P6	Declared brain-dead patient whose organs are being removed for donor purposes (informational only).

Anesthesia modifiers must be appended per UCare billing rules with the appropriate anesthesia modifier in the first modifier position on the claim. The MAC informational modifiers G8 and G9 indicate monitored anesthesia care conditions and are informational; when used, the personally performed or appropriate medical direction modifier must also be submitted. The QS modifier is informational and must be in the secondary position. Providers must also report the actual anesthesia minutes (exact number of minutes from preparation for induction until the anesthesiologist or CRNA was no longer in personal attendance) on the claim; only anesthesia minutes should be entered in the service unit count field.

Billing rules, documentation, and payment calculations

Billing Rule

Claim submission format

Submit anesthesia claims using the MN-ITS 837P or electronic equivalent and bill with the specific ASA/CPT anesthesia or surgical code with the appropriate anesthesia modifier placed in the first modifier position.

Use MN-ITS 837P or electronic equivalent.
Use specific ASA/CPT anesthesia or surgical code.
Place appropriate anesthesia modifier in the first modifier position.

Billing Rule

Report exact anesthesia minutes

Report the exact number of anesthesia minutes from preparation of the patient for induction until the anesthesiologist or CRNA was no longer in personal attendance; enter only the anesthesia minutes in the service unit count field — UCare will add the base units for each procedure.

Time period: preparation for induction to end of personal attendance.
Enter only anesthesia minutes in the service unit count field.
UCare adds base units for each procedure.

Documentation Required

Teaching anesthesiologist documentation

To bill at the personally performed rate for a teaching anesthesiologist, the medical record must document the teaching anesthesiologist's presence and participation during induction, emergence, and all critical portions of the procedure and that the teaching anesthesiologist was immediately available for the entire service.

Document presence and participation during induction, emergence, and critical portions.
Document immediate availability throughout the entire service.

Billing Rule

Use of modifiers and payment calculation

Append the appropriate anesthesia modifiers and apply the payment formulas: AA or GC (personally performed or teaching) = (Base Units) + (Time Units/15) x Conversion Factor; QK/QX/QY (medically directed or CRNA with direction) = ((Base Units) + (Time Units/15) x Conversion Factor) x 0.632; QZ = (Base Units) + (Time Units/15) x Conversion Factor; G8/G9/QS are informational for MAC and must be submitted with the personally performed or appropriate medical direction modifier and actual time on the claim.

AA, GC: (Base Units) + (Time Units/15) x Conversion Factor.
QK, QX, QY: same formula x 0.632 multiplier.
QZ: (Base Units) + (Time Units/15) x Conversion Factor.
G8/G9/QS: informational for MAC — submit with primary modifier and actual time.

Denial Risk

Surgeon supervision not reimbursed

Claims submitted for surgeon supervision of anesthesia services when supervising an Anesthesia Assistant, CRNA, intern, or resident will not be reimbursed.

Surgeon supervision of Anesthesia Assistant, CRNA, intern, or resident = not reimbursed.

Billing Rule

Concurrent supervision payment cap

When an anesthesiologist supervises five or more concurrent procedures, payment for eligible services personally performed by the anesthesiologist shall not exceed three base units and one additional unit for induction.

Cap applies when supervising ≥ five concurrent procedures.
Maximum payment: 3 base units + 1 unit for induction.

Billing Rule

Pre-anesthetic evaluation payment

The anesthesia base value includes the pre-anesthetic evaluation and usual pre/post-operative visits; no separate payment is allowed unless the anesthetic was not administered because the surgery was canceled, in which case an E/M may be billed.

Pre-anesthetic and routine pre/post-op visits included in base value.
If anesthetic not administered due to cancellation, bill appropriate E/M code.

OpenPayer

Anesthesia (MHCP)

Policy summary and scope

Eligibility and coverage criteria

Modifiers and code groups

Billing rules, documentation, and payment calculations

Key terms

Medicare/CMS adoption and related notes

Policy changes and review timeline