CurrentUnitedHealthcarePolicy 2025R0032B

Reimbursement policy — Anesthesia services (CMS-1500)

Defines UnitedHealthcare Community Plan's reimbursement methodology and billing rules for anesthesia services billed on the CMS-1500 (and electronic equivalent) for Community Plan Medicaid products, and applies to all network and non-network physicians and qualified health care professionals.

Policy Summary

PayerUnitedHealthcare

PolicyAnesthesia reimbursement and billing rules for services billed on CMS-1500 (Community Plan Medicaid)

Policy CodePolicy 2025R0032B

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionReport anesthesia services on the CMS-1500 (or electronic equivalent) with required anesthesia modifiers and one-minute increment time reporting; submit supporting documentation on paper CMS-1500 when requested.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

00100-01999Anesthesia CPT range

1-minTime reporting precision

50%/100%Modifier percentages (examples)

99100,99116,99135,99140Qualifying circumstance codes

multiple

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Base+Time01967 method

Anesthesia Coverage and Billing Criteria

Anesthesia coverage and billing rules

Reimbursement determination follows base units, time units, modifying units, conversion factor and modifier percentage; bundling and duplication rules apply.

Standard Anesthesia Formula without AD = ([Base Unit Value + Time Units + Modifying Units] x Conversion Factor) x Modifier Percentage.

Standard Anesthesia Formula with AD = ([Base Unit Value of 3 + 1 Additional Unit if anesthesia notes indicate the physician was present during induction] x Conversion Factor) x Modifier Percentage.

Anesthesia time must be reported as actual anesthesia time in one-minute increments; time spent placing blocks before induction or after emergence should not be added to anesthesia time.

All anesthesia services must be submitted with a required anesthesia modifier in the first modifier position; the modifier percentage adjusts the Allowed Amount per the modifier table.

Qualifying circumstance codes (99100, 99116, 99135, 99140) are recognized but do not allow additional base units.

When multiple surgical procedures are performed during a single anesthesia administration, report only the single anesthesia code with the highest Base Unit Value and report combined total anesthesia time for all procedures on that date for that patient.

Duplicate anesthesia codes reported for the same patient on the same date are reimbursed only once; simultaneous MD and CRNA administrations during the same operative session may each receive 50% when appropriate modifiers (QK/QY and QX) are reported.

An additional anesthesia administration during a different operative session on the same day may be reimbursed when appended with modifier 59, 76, 77, 78, 79 or XE; for each session report only the single anesthesia code with the highest Base Unit Value.

Procedural or pain management services identified as bundled (integral) are not separately reimbursable when performed by the Same Individual on the same date of service unless a distinct-encounter modifier (59, XE or XU) is appended to indicate a separate encounter.

Bundling and crosswalk rules

Bundling and crosswalk criteria

Do not separately bill anesthesia services when performed by the Same Individual Physician or Other Qualified Health Care Professional as the medical or surgical procedure on the same date of service; the allowance for anesthesia is included in the payment for the procedure (append modifier 47 to the surgical code when physician performs both).

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UnitedHealthcare Community Plan references CMS NCCI methodologies and ASA crosswalks to identify procedural/pain management services that are integral to anesthesia; listed CPT/HCPCS codes identified as bundled are not separately reimbursable when performed by the Same Individual unless modifier 59, XE or XU indicates a distinct procedural service.

An extensive table of specific procedural/pain management CPT codes is provided in the policy showing crosswalks and bundled relationships to anesthesia codes; consult the policy tables for code-level guidance.

Exceptions and calculation methods

Separate reimbursement exceptions and methods

Critical care E/M codes 99291-99292 are not included in anesthesia services and will be separately reimbursed when reported the same date as an anesthesia service.

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CPT 01967 (neuraxial labor analgesia) is reimbursed based on Base Unit Value plus Time Units consistent with the ASA RVG® method.

Obstetric add-on codes 01968 and 01969 may be considered for reimbursement when reported by the same or a different provider than the primary 01967; time for add-on codes is reported separately and is not added to the time reported for the labor anesthesia service.

State exceptions

State-specific modifier and billing exceptions

State-specific modifier adjustments: Reimbursement percentages, allowed modifiers, and billing requirements for anesthesia modifiers (e.g., AD, QK, QY, QX, QZ) vary by state; refer to state-specific rules (examples include FL, IN, KS, KY, MN, MO, NE, NY, RI, TX, VA, DC, WI).

Florida: modifier AD reimburses at 50% of the allowed amount; reimbursement for modifiers QK/QY is 20%, QX/QZ is 80%; epidural anesthesia codes 01967 (and 01967 + 01968) must be limited to no more than 360 minutes (24 units) for vaginal or cesarean delivery.

Indiana: modifier AD reimburses at 50%; modifiers may be appended in any position; certain Q modifiers (e.g., QY) may be denied; CPT 01996 is not paid on the same day as epidural placement but may be billed on subsequent days when managed; altered circumstance reporting may not apply as in other states; Indiana has special time unit billing rules for 01960 and 01967 and limits on qualifying codes as noted in state regulations.

Kansas and other listed states: modifier AD often reimburses at 50% per state regulation; states may impose additional restrictions such as only direct face-to-face time being reimbursable or noncoverage of certain modifiers—follow the state-specific provisions in the policy.

Anesthesia billing and coverage rules

Key coverage and billing rules and examples from the policy:

For general or monitored anesthesia services supporting a non-anesthesia service, report the appropriate CPT anesthesia code (00100-01999) per the ASA CROSSWALK®.

If a physician personally performs both the anesthesia and the surgical/medical procedure, append modifier 47 to the surgical/medical code and do not report CPT anesthesia section codes.

If surgery is cancelled after the preoperative exam but before patient prepared for induction, report the E/M exam only; if cancelled after the patient has been prepared for induction, report the most applicable anesthesia code with full base and time.

CRNA services should be reported with modifiers QX or QZ and generally reported under the supervising physician's or employer's name unless the CRNA is individually contracted and credentialed by UnitedHealthcare Community Plan, in which case report under the CRNA's name.

Teaching anesthesiologist may report actual Anesthesia Time for two resident cases using modifiers AA or GC consistent with CMS policy.

Codes, Modifiers and Time Reporting

Required Anesthesia Modifiers and PercentagesModifier

AA	Anesthesia services personally performed by the anesthesiologist — Reimbursement Percentage = 100%
AD	Medical supervision by a physician — Reimbursement Percentage = 100%
QK	Medical direction of two, three, or four concurrent anesthetists — Reimbursement Percentage = 50%
QX	CRNA service with medical direction by a physician — Reimbursement Percentage = 50%
QY	Medical direction of one certified registered nurse anesthetist (CRNA) by an anesthesiologist — Reimbursement Percentage = 50%
QZ	CRNA service — Reimbursement Percentage = 100%
XU	Unusual non-overlapping service by the same physician — Reimbursement Percentage = 100% (applies when billed to indicate distinct procedural service per CMS guidance)

Qualifying Circumstance Codes (No Additional Base Units)CPTNot Covered

99100	Qualifying circumstance — no additional base units allowed
99116	Qualifying circumstance — no additional base units allowed
99135	Qualifying circumstance — no additional base units allowed
99140	Qualifying circumstance — no additional base units allowed

Modifiers Affecting Reimbursement (examples)Modifier

AA	100% — personally performed (use in first modifier position)
AD	100% — medical supervision modifier; affects standard formula when present
QK	50% — medical direction of multiple concurrent anesthetists
QX	50% — CRNA with medical direction
QY	50% — medical direction of one CRNA
QZ	100% — CRNA service
XU	100% — distinct procedural service (use per CMS to indicate separate, non-overlapping service)

Procedural CPT Codes Bundled into Anesthesia (examples)CPTNot Covered

62321	Procedural/pain management code — bundled into anesthesia per policy examples
64415	Procedural/pain management code — bundled into anesthesia per policy examples
64466	Procedural/pain management code — bundled into anesthesia per policy examples
64505	Procedural/pain management code — bundled into anesthesia per policy examples

HCPCS Procedural Codes Bundled with Anesthesia (examples)HCPCSNot Covered

G0104	HCPCS example with bundled anesthesia services listed
G0339	HCPCS example with bundled anesthesia services listed
G0412	HCPCS example with bundled anesthesia services listed

Anesthesia CPT RangeCPT

00100-01999

CPT anesthesia codes — base values assigned by ASA; UnitedHealthcare uses these for reimbursement

Epidural/Subarachnoid Injection ReportingCPTCovered

01967	Neuraxial labor analgesia — reimbursed by Base Unit Value plus Time Units per policy (see neuraxial labor analgesia section)
62320-62327	Epidural or subarachnoid injections — may be separately reported for postoperative pain management when not used for operative anesthesia; modifier 59, XE, or XU must be appended to indicate distinct procedural service

Modifiers to Identify Altered Circumstances (No Additional Reimbursement Above Usual Fee)ModifierNot Covered

23	Unusual procedural services — when reported for anesthesia/pain management, no additional reimbursement above usual fee
47	Anesthesia performed by same physician performing procedure — no additional reimbursement above usual fee; see Q&A guidance
GC	Medically necessary, certified — when used to indicate altered circumstance with anesthesia/pain management, no additional reimbursement above usual fee
G8	Indicator for Monitored Anesthesia Care — used to identify MAC; when reported as altered circumstance no additional base units
G9	Indicator for Monitored Anesthesia Care — used to identify MAC; when reported as altered circumstance no additional base units
QS	Monitored Anesthesia Care — sedation service by a physician; when reported as altered circumstance no additional reimbursement above usual fee

inv-14: 01967 reimbursement units — 01967 reimbursed by Base Unit Value plus Time Units.

01967 calculation noteNeuraxial labor analgesia (CPT 01967) will be reimbursed based on Base Unit Value plus Time Units as described in policy.

inv-15: Time reporting increment — actual anesthesia time required in one-minute increments; time units derived by 15-minute blocks.

Time reporting granularityConsistent with CMS guidelines, UnitedHealthcare requires actual anesthesia time reported in one-minute increments; time units are calculated using 15-minute blocks. Use CMS-1500 field 24G (Days or Units) or electronic equivalents for minutes/units.

Provider Responsibilities and Billing Actions

Note

Applicability and claim submission responsibility

This reimbursement policy applies to UnitedHealthcare Community Plan Medicaid products and to services billed on the CMS-1500 (1500 Health Insurance Claim Form) or its electronic equivalent. It applies to all products and to all network and non-network physicians and other qualified health care professionals, including non-network authorized and percent-of-charge contract providers. Providers are responsible for submission of accurate claims. UnitedHealthcare Community Plan may use reasonable discretion in interpreting or applying this policy and may modify the policy by publishing a new version.

Applies to UnitedHealthcare Community Plan Medicaid products
Applies to services reported using CMS-1500 or electronic equivalent
Applies to all network and non-network physicians and qualified health care professionals
Providers must submit accurate claims; UnitedHealthcare retains discretion to interpret/modify policy

Policy Definitions

Definitive vs Interpretive source

Definitive sourceA Definitive source contains very specific instructions or exact codes/modifiers from the given source; used without interpretation.

Interpretive sourceAn Interpretive source provides guidelines requiring interpretation to correlate codes or modifiers to the guidance; subject to clinical/policy interpretation.

UsageUnitedHealthcare references Definitive or Interpretive methodologies when determining bundled or integral anesthesia/procedural services.

Same Individual

DefinitionThe Same Individual is the same individual rendering health care services and reporting the same Federal Tax Identification number.

ImplicationServices performed by the Same Individual on the same date that are identified as bundled are not separately reimbursable.

Policy Summary

PayerUnitedHealthcare

PolicyAnesthesia reimbursement and billing rules for services billed on CMS-1500 (Community Plan Medicaid)

Policy CodePolicy 2025R0032B

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

When multiple separate anesthesia administrations occur on the same date for the same patient, report each anesthesia CPT with appropriate modifier and time; append modifier 59, 76, 77, 78, 79 or XE as needed to indicate separate subsequent services.

Anesthesia assistants should report with modifier QX and supervising physicians should report with QK, QY or AD when medically directing an AA; UnitedHealthcare aligns AA reimbursement eligibility with CRNA levels but AAs must be medically directed.

Brain function monitors for intraoperative awareness are not separately reportable when used in conjunction with an anesthetic service.

Epidural or subarachnoid injection codes (62320-62327) may be separately reported for postoperative pain management with an anesthesia code (e.g., 01470) if not used for operative anesthesia; append modifier 59, XE or XU to indicate a distinct procedural service.

Documentation and claim submission: report actual minutes on paper claims using CMS 1500 format 02-12 field 24G (Days or Units) and on electronic claims using 837P SV104 Service Unit Count; follow NUCC guidance for formatting (minutes, left-justified, no leading zeros).

Reimbursement is based on the specific modifier reported; refer to the Reimbursement Formula and Modifiers sections of the policy for modifier percentage and calculation details.

Billing Rule

Daily hospital management billing

CPT code 01996 (daily hospital management for epidural or subarachnoid drug administration) is separately reimbursable once per date of service (excluding the day of insertion) when provided in CMS places of service 19, 21, 22 or 25. CPT code 01996 is considered included in the pain management procedure if submitted on the same date of service by the Same Individual Physician or Other Qualified Health Care Professional. If the anesthesiologist continues care after discharge, submit the appropriate Evaluation and Management code.

01996 reimbursable once per date (excluding insertion day)
Places of service: 19 (off-campus outpatient hospital), 21 (inpatient hospital), 22 (on-campus outpatient hospital), 25 (birthing center)
01996 included in pain management procedure if billed same date by same individual
If anesthesiologist continues care after discharge, bill appropriate E/M code

Documentation Required

Submission of supporting documentation

When UnitedHealthcare Community Plan requests supporting documentation, submit a paper CMS claim form accompanied by the requested documentation to support the billed services.

Submit a paper claim using the CMS-1500 form with requested supporting documentation

ExamplesApplies to physicians or other qualified health care professionals when anesthesia and procedural services are performed by the same provider entity.

Allowable Amount

DefinitionAllowable Amount is the dollar amount eligible for reimbursement to the physician or other qualified health care professional on the claim (contracted rate, reasonable charge, or billed charges as applicable).

Contract considerationsFor percent of charge or discount contracts, the Allowable Amount is the billed amount less the discount.

Role in calculationsModifier Percentages are applied to the Allowable Amount when adjusting anesthesia reimbursement according to reported modifiers.

Anesthesia Time

Start and endAnesthesia Time begins when the Anesthesia Professional prepares the patient for induction in the operating room or equivalent area and ends when the Anesthesia Professional is no longer in personal attendance and patient may be safely placed under postoperative supervision.

Continuous presenceAnesthesia Time involves the continuous actual presence of the Anesthesia Professional throughout the period reported.

ExclusionsDo not include time before patient prepared for induction or after professional no longer in personal attendance when calculating anesthesia time.

Anesthesia Professional

Who qualifiesAnesthesia Professional includes an Anesthesiologist, Certified Registered Nurse Anesthetist (CRNA), Anesthesia Assistant (AA), or other qualified individual working independently or under medical supervision.

Duties includedIncludes preoperative and postoperative visits, administration of fluids/blood incident to anesthesia, and interpretation of non-invasive monitoring when part of anesthesia care.

Reporting implicationsAnesthesia services must be reported with required anesthesia modifiers identifying the role of the Anesthesia Professional (e.g., AA, QK, QX, QZ).

Base Unit Value

DefinitionBase Unit Value is the number of units representing the Base Value (per anesthesia code) for usual anesthesia services, excluding time actually spent in anesthesia care and any Modifying Units.

What base coversBase Value includes usual preoperative and postoperative visits, administration of fluids/blood incident to anesthesia, and interpretation of non-invasive monitoring; certain invasive procedures are not included.

Use in formulaBase Unit Value is the non-time component used in the Standard Anesthesia Formula for reimbursement calculations.

Moderate Sedation

Clinical definitionModerate (conscious) Sedation is a drug-induced depression of consciousness where patients respond purposefully to verbal commands (with or without light tactile stimulation); no interventions required to maintain airway and spontaneous ventilation is adequate.

ExclusionsModerate Sedation does not include minimal sedation (anxiolysis), deep sedation, or monitored anesthesia care (CPT 00100-01999).

Functional pointsCardiovascular function is usually maintained during moderate sedation.

Monitored Anesthesia Care

Scope of careMonitored Anesthesia Care (MAC) includes pre-procedure visit, intra-procedure care, and post-procedure anesthesia management, and may include varying levels of sedation, analgesia, and anxiolysis.

Provider readinessProvider of MAC must be prepared and qualified to convert to general anesthesia when necessary.

ModifiersModifiers G8, G9 and QS are used to identify Monitored Anesthesia Care.

Same Individual Physician or Other Qualified Health Care Professional

DefinitionSame Individual Physician or Other Qualified Health Care Professional: the same individual rendering services and reporting the same Federal Tax Identification number.

Billing effectWhen anesthesia and procedural/pain management services are performed by the Same Individual on the same date and are identified as bundled, they are not separately reimbursable.

ReferenceUnitedHealthcare applies Definitive or Interpretive source methodologies when determining bundling for services performed by the Same Individual.

Same Specialty Physician or Other Qualified Health Care Professional

DefinitionSame Specialty Physician or Other Qualified Health Care Professional: physicians and/or other qualified health care professionals of the same group and same specialty reporting the same Federal Tax Identification number.

Billing implicationE/M services reported by the same specialty physician or qualified professional on the same date as anesthesia are generally not separately reimbursable (exceptions apply, e.g., critical care codes).

GroupingUsed by UnitedHealthcare to determine when services are considered part of the same provider group for bundling decisions.

Moderate Sedation (alternate)

Clinical definitionModerate Sedation: patient responds purposefully to verbal commands (alone or with light tactile stimulation); spontaneous ventilation adequate and cardiovascular function usually maintained.

Exclusion noteDoes not include minimal sedation, deep sedation, or monitored anesthesia care.

ContextUsed to differentiate sedation levels for billing and coverage determinations.

Monitored Anesthesia Care (alternate)

DefinitionMonitored Anesthesia Care: comprehensive anesthesia care including pre-, intra-, and post-procedure management; provider must be ready to convert to general anesthesia and MAC may include variable sedation levels.

ModifiersUse G8, G9, QS to identify MAC.

Coverage noteMAC services are treated as anesthesia services for reporting and reimbursement under CPT 00100-01999.

Same Individual Physician or Other Qualified Health Care Professional (additional)

DefinitionSame Individual Physician or Other Qualified Health Care Professional: the same individual rendering services and reporting the same Federal Tax Identification number.

RelevanceThis designation determines when services are considered bundled and not separately reimbursable.

ApplicationReferenced in bundling and crosswalk determinations within the policy.

Time Units

DefinitionTime Units are derived by dividing reported actual anesthesia minutes by a time increment generally of 15 minutes; UnitedHealthcare requires actual anesthesia time be reported in one-minute increments.

ConversionConvert minutes to Time Units for reimbursement by dividing total minutes by 15 (per Time Units guidance).

Claim reportingReport minutes on claims (paper or electronic) and map to units for payment calculations per the Standard Anesthesia Formula.

Standard Anesthesia Formula

DefinitionStandard Anesthesia Formula refers to the formula used with or without Modifier AD to calculate reimbursement: without AD = ([Base Unit Value + Time Units + Modifying Units] x Conversion Factor) x Modifier Percentage; with AD = ([Base Unit Value of 3 + 1 additional unit if physician present during induction] x Conversion Factor) x Modifier Percentage.

When to use ADUse the 'with AD' variation when documentation indicates the physician was present during induction and AD modifier applies as defined in policy/state rules.

Role of modifiersModifier Percentage (e.g., AA, QK/QX/QY) is applied to the formula's result to determine final reimbursement amount.