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Anesthesia Policy, Professional - Reimbursement Policy - UnitedHealthcare Community Planopen_in_new

UnitedHealthcare Community Plan reimbursement policy defining coding, modifier requirements, time reporting, formulas, bundling rules, state exceptions, and billing guidance for anesthesia services (CPT 00100-01999) billed on CMS-1500 or electronic equivalent for Medicaid products.

Policy Summary

PayerUnitedHealthcare

PolicyAnesthesia Policy, Professional - Reimbursement Policy - UnitedHealthcare Community Planopen_in_new

Policy CodePolicy N/A

Change TypeMultiple revisions (state exceptions, bundling, annual review)

Effective Date

Next Review Date

Key ActionSubmit CPT anesthesia code 00100-01999 (excluding 01953 and 01996) with a required anesthesia modifier in the first modifier position and report actual anesthesia time in one-minute increments.

SourceLink

POLICY UPDATE CHANGES

Anesthesia Services Bundled into HCPCS Procedural Codes section updated.

Annual review and version update; history entries prior to 2/1/2024 archived.

State Exceptions section: Idaho added.

State Exceptions section: California removed.

Reimbursement Guidelines: Procedural or Pain Management Codes Bundled into Anesthesia and Procedural or Pain Management Bundled Codes Allowed with Modifiers table updated.

State Exceptions section: Wisconsin updated.

State Exceptions section: Indiana updated.

Policy implemented by UnitedHealthcare Community & State.

1Anesthesia code range focused

4Qualifying circumstance codes listed

3Primary reimbursement formulas

multipleState exceptions detailed

3Billing/reporting action items

1Explicit non-separately reportable item

Policy scope and alignment

This UnitedHealthcare Community Plan reimbursement policy governs anesthesia services billed with CPT anesthesia codes 00100-01999 (excluding 01953 and 01996) and defines coding, modifier requirements, time reporting, reimbursement formulas, bundling rules, claim reporting mapping, state-specific exceptions, and billing guidance for Medicaid products.

The policy aligns to the American Society of Anesthesiologists' resources (ASA Relative Value Guide and ASA CROSSWALK) and Centers for Medicare and Medicaid Services guidance (CMS NCCI policy and CMS National Physician Fee Schedule) to determine base unit values, bundling edit logic, and crosswalks between anesthesia and procedural/HCPCS codes.

Scope includes: use of ASA-assigned Base Unit Values; reporting anesthesia time in one-minute increments; required first-position anesthesia modifiers that determine Modifier Percentage; the Standard Anesthesia Formula for reimbursement (with special AD handling); rules for multiple or duplicate anesthesia services and MD/CRNA simultaneous services; identification of procedural/pain management codes that are bundled into anesthesia and the modifiers (59/XE/XU) that may indicate distinct procedural services; mapping guidance for paper (CMS-1500 item 24G) and electronic (837P loop 2400/SV104) claim reporting; and state-specific deviations from the base policy.

Anesthesia reporting and coverage criteria

Anesthesia Services Reporting Rules

Anesthesia services must meet the following reporting requirements:

Anesthesia CPT range and exclusions: Anesthesia services must be submitted with a CPT anesthesia code in the range 00100-01999, excluding 01953 and 01996.

01953 and 01996 are not considered time-based anesthesia services per ASA RVG®

Modifier position: All anesthesia services including Monitored Anesthesia Care must be submitted with a required anesthesia modifier in the first modifier position.

Modifiers identify personal performance, medical direction or supervision and affect reimbursement percentage.

Time reporting increments: Time-based anesthesia services must be reported with actual anesthesia time in one-minute increments.one-minute increments

Report total minutes (e.g., 60 for one hour).

Multiple procedures during single anesthesia: When multiple surgical procedures occur during a single 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 (01953, 01968, 01969) are exceptions per policy.

Duplicate (same) anesthesia codes: When duplicate anesthesia codes are reported for the same patient on the same date, only the first submission is reimbursed; exception: simultaneous MD and CRNA services may each receive 50% when reported with QK (or QY) and QX modifiers.

Reimbursement percentages per modifier table.

Reimbursement Formula

Time-based anesthesia services are reimbursed according to the Standard Anesthesia Formula:

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

Apply Modifier Percentage from modifier table or state exception.

Standard formula with AD: Standard Anesthesia Formula with Modifier AD: ([Base Unit Value of 3 + 1 additional unit if documentation indicates the physician was present during induction] x Conversion Factor) x Modifier Percentage.

Documentation of physician presence during induction is required to allow the additional unit when using AD.

Qualifying Circumstances

Qualifying circumstance codes are recognized but do not add base units:

Qualifying circumstance codes (99100, 99116, 99135, 99140) identify conditions affecting anesthesia but are not allowed additional base units.

Consistent with CMS guidelines.

Bundling Rules

Procedural/pain management services integral to anesthesia are not separately reimbursable when performed by the same individual on the same date of service unless properly modified:

Bundled procedural/pain codes: Procedural/pain management codes identified as bundled (e.g., CMS status indicator B or T and listed CPT/HCPCS codes in policy) are not separately reimbursable when performed by the Same Individual on the same date of service.

Refer to policy tables for full code lists.

Use of 59/XE/XU to report distinct services: Anesthesia professionals may identify separate distinct encounters by appending modifier 59, XE, or XU to the procedural/pain management code to indicate a distinct procedural service when appropriate.

Codes listed as bundled will be considered distinct when 59, XE or XU is appended per the policy tables.

Anesthesiologist performing procedure: When an anesthesiologist personally performs the medical/surgical procedure, the anesthesia service is included in the surgical/procedural payment and modifier 47 should be appended to the surgical code; anesthesia section codes are not used separately.

Consistent with NCCI and AMA guidance.

Daily Hospital Management and Obstetric Rules

01996 daily management frequency: Daily hospital management of epidural or subarachnoid drug administration (CPT 01996) is separately reimbursable once per date of service excluding the day of insertion when provided in CMS place of service 19, 21, 22 or 25; 01996 is considered included in the pain management procedure if submitted on the same date by the Same Individual.Once per date of service excluding day of insertion

If anesthesiologist continues care after discharge, use appropriate E/M codes.

Neuraxial labor analgesia (01967): Neuraxial labor analgesia (CPT 01967) is reimbursed based on Base Unit Value plus Time Units.

Follow ASA RVG® method described in policy.

Obstetric add-on codes 01968/01969: Obstetric add-on CPT codes 01968 and 01969 may be reimbursed when reported by the same or a different individual than the primary 01967; time for 01968/01969 is reported separately and is not added to 01967 time.

Add-on codes treated as separate surgical anesthesia services per ASA Crosswalk®.

Reporting anesthesia service units/minutes on claims

Instructions for how anesthesia minutes or units should be reported on paper and electronic claims:

Paper claims (CMS 1500 item 24G): On CMS 1500 paper claims (02-12), complete item 24G 'Days or Units' and report anesthesia services as minutes (left-justified, no leading zeros); units are allowed only when the code description includes a time period (e.g., daily management).minutes

If only one service performed enter '1' in appropriate context; use decimal for fractions.

Electronic claims (837P SV104): Electronic claims (837P v5010/5010A1) map 24G/Days or Units to loop 2400/SV104 Service Unit Count (SV104) to report anesthesia minutes.

Service Unit Count corresponds to minutes reported.

Unit/minute reporting rules: Time-based anesthesia services must be reported in one-minute increments; units may be used only when the CPT code description includes a time period (e.g., 'daily management').

Anesthesia teaching services reporting and reimbursement

Guidance and reimbursement determinants for anesthesia teaching services:

Federal Register guidance: Refer to the Department of Health and Human Services Federal Register publication (Nov 25, 2009, p. 61867) for detailed reporting guidance for anesthesia teaching programs.

Link provided in Resources/Federal Register section.

Modifier-based reimbursement for teaching services: Reimbursement for anesthesia teaching services is determined based on the specific anesthesia modifier reported (e.g., AA or GC) and follows the Standard Anesthesia Formula and modifier percentage rules.

Teaching anesthesiologist may report actual Anesthesia Time for each case with appropriate modifiers.

Brain function monitor for intraoperative awareness

Whether brain function monitors are separately reportable with anesthesia:

Brain function monitor not separately reportable: Use of a brain function monitor for intraoperative awareness is not separately reportable in conjunction with an anesthetic service according to the ASA RVG®.

Policy Q&A cites ASA RVG® guidance.

Epidural/subarachnoid injections performed for postoperative pain management

When CPT 62320-62327 may be reported on the date of surgery with an anesthesia code:

Separate reporting for postoperative pain management: CPT 62320-62327 may be separately reported on the date of surgery when performed for postoperative pain management rather than as the means for providing the regional block for the surgical procedure; the injection must not have been utilized for operative anesthesia.

Policy allows separate reporting if used for postoperative pain management.

Modifier requirement for distinct epidural/subarachnoid injections: Modifier 59, XE or XU must be appended to the epidural or subarachnoid injection code (62320-62327) to indicate a distinct procedural service when reported on the date of surgery.

Append 59/XE/XU per CMS NCCI guidance and policy tables.

Code groups and modifier guidance

Billing rules, documentation, and submission requirements

Billing Rule

Submit anesthesia codes and modifiers

Submit anesthesia CPT codes in the 00100–01999 range (01953 and 01996 are excluded from time-based anesthesia reporting). Always report a required anesthesia modifier in the first modifier position. Report actual anesthesia time in one-minute increments.

CPT anesthesia codes: 00100-01999 (exclude 01953 and 01996).
Required anesthesia modifier must be in first modifier position.
Report anesthesia time as minutes in one-minute increments.

Billing Rule

Apply Standard Anesthesia Formula

Calculate reimbursement using the Standard Anesthesia Formula and apply the Modifier Percentage (or applicable state exception). Use the formula without AD: ([Base Unit Value + Time Units + Modifying Units] x Conversion Factor) x Modifier Percentage. If using modifier AD, use the AD formula and apply AD reimbursement rules or state exceptions.

Key terms

Definitions (brief)

Allowable AmountDollar 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).

Anesthesia TimeBegins when the Anesthesia Professional prepares the patient for induction in the OR or equivalent area and ends when no longer in personal attendance; involves continuous actual presence; report actual anesthesia time in one-minute increments.

Anesthesia ProfessionalAn Anesthesiologist, Certified Registered Nurse Anesthetist (CRNA), Anesthesia Assistant (AA), or other qualified individual working independently or under medical supervision.

Base Unit ValueNumber of units representing the Base Value per anesthesia CPT code (excludes time and modifying units); used to determine reimbursement per code.

Modifier PercentageReimbursement percentage allowed for anesthesia services based on the required anesthesia modifier (examples: AA=100%, AD=100%, QK/QX/QY=50%, QZ=100% — state exceptions may vary).

Frequently asked questions (quick answers)

FAQs

Unsupported block type: p

Answers

Unsupported block type: p

Medicare determinations & external guidance

The policy references the CMS Federal Register entry 'Improvements for Medicare Anesthesia Teaching Programs' (Federal Register, Nov 25, 2009) for guidance on reporting anesthesia teaching services and aligns teaching-service reimbursement with CMS NCCI and MPFS methodologies.

Consistent with CMS guidance and this policy, reimbursement for teaching anesthesiologist services is driven by the specific anesthesia modifier reported and CMS rules on medically directed versus personally performed services; the Federal Register citation (Nov 25, 2009, p. 61867) is provided as the source for detailed teaching program reporting instructions.

Policy thresholds and limits

Thresholds

Anesthesia time reporting incrementOne-minute increments (report actual anesthesia time in minutes).

Daily epidural management reimbursement frequencyCPT 01996 reimbursable once per date of service excluding the day of insertion (separately reimbursable in specified CMS places of service).

Policy changes and effective history

3/25/2006implementation

Policy implemented by UnitedHealthcare Community & State.

3/30/2025revised

Reimbursement Guidelines: Procedural or Pain Management Codes Bundled into Anesthesia and Procedural or Pain Management Bundled Codes Allowed with Modifiers table updated.

7/13/2025revised

State Exceptions section: California removed.

Policy Summary

PayerUnitedHealthcare

PolicyAnesthesia Policy, Professional - Reimbursement Policy - UnitedHealthcare Community Planopen_in_new

Policy CodePolicy N/A

Change TypeMultiple revisions (state exceptions, bundling, annual review)

Effective Date

Next Review Date

SourceLink

On This Page

one-minute increments

See policy definitions and examples.

Standard formula without AD: ([Base Unit Value + Time Units + Modifying Units] x Conversion Factor) x Modifier Percentage.
Standard formula with AD: ([Base Unit Value of 3 + 1 additional unit if documentation shows physician present during induction] x Conversion Factor) x Modifier Percentage.
Apply the modifier percentage from the modifier table or applicable state exception.

Billing Rule

Bundle recognition and use of modifiers to unbundle

Procedural and pain management codes identified as bundled (CMS status indicator B or T and codes listed in the policy tables) are not separately reimbursable when performed by the Same Individual. To report a procedural/pain code separately when appropriate, append modifier 59, XE, or XU to indicate a distinct procedural service.

Bundled codes (status B/T and listed codes) are included in anesthesia and not separately reimbursable when furnished by the Same Individual.
Append modifier 59, XE or XU to the procedural code to indicate a distinct encounter and allow separate reporting.
Nerve block codes billed without 59/XE/XU in conjunction with anesthesia are treated as bundled.

Billing Rule

Duplicate code reimbursement

When identical anesthesia codes are submitted for the same patient on the same date, only the first submission will be reimbursed. Exception: when an MD and a CRNA administer anesthesia simultaneously during the same operative session and report appropriate Q modifiers (e.g., QK/QY and QX), each may receive 50% of the Allowed Amount.

Only first submission of duplicate anesthesia code reimbursed for same patient/date.
Simultaneous MD and CRNA may each receive 50% when reported with proper Q modifiers (e.g., QK or QY and QX).

Documentation Required

Physician presence for AD formula

When applying the Modifier AD formula, the anesthesia record must document physician presence during induction to support the additional unit in the AD formula.

Documentation must indicate physician presence during induction to allow the additional AD unit.

Billing Rule

CRNA reporting requirements

CRNA services should be reported with appropriate CRNA modifiers (QX or QZ) and must be submitted under the supervising physician's name or the contracted employer/entity name. In limited circumstances, when the CRNA is individually contracted/credentialed by the plan, report under the CRNA.

Report CRNA services with modifier QX or QZ.
Claims must be submitted under supervising physician or contracted employer/entity name unless CRNA is individually contracted/credentialed.

Billing Rule

Anesthesiologist performing procedure

If the anesthesiologist personally performs the anesthesia and also performs the surgical/procedural service, append modifier 47 to the surgical code and do not report codes from the anesthesia section.

Append modifier 47 to the surgical code when the same physician performs the surgery and anesthesia.
Do not report anesthesia section CPT codes when modifier 47 is used by the same physician.

Billing Rule

Paper claim time reporting

On CMS 1500 paper claims (02-12), enter anesthesia minutes in item 24G (Days or Units) as minutes: left-justify numbers, do not use leading zeros, and use a decimal point only for fractions. Units may be used only when the code description specifies a time period (e.g., daily management).

Enter minutes in CMS 1500 item 24G as left-justified numbers with no leading zeros.
Report anesthesia as minutes; units allowed only when code specifies a time period (e.g., daily management).

Documentation Required

Paper claim support documentation submission

When the policy requests supporting documentation, submit a paper claim on the CMS form accompanied by the requested supporting documentation.

Include the requested supporting documentation with the paper CMS-1500 claim submission.

Billing Rule

Report anesthesia as minutes on claims

Report anesthesia services as minutes on claims: map CMS 1500 item 24G (Days or Units) to the 837P electronic Service Unit Count (Loop 2400/SV104). Ensure anesthesia time is reported in minutes (one-minute increments); units may only be used when the code description specifies a time period.

Paper: CMS 1500 item 24G = minutes (02-12 format).
Electronic: map 24G to 837P Loop 2400/SV104 Service Unit Count.
Report anesthesia time in one-minute increments; units only when code description includes a time period.

Billing Rule

Use modifiers to report distinct epidural/subarachnoid injections

When CPT codes 62320–62327 are reported on the date of surgery for postoperative pain management (not as the operative regional block), append modifier 59, XE or XU to the injection code to indicate a distinct procedural service.

CPT 62320–62327 may be separately reported for postoperative pain management if not used for operative anesthesia.
Append modifier 59, XE, or XU to indicate the injection is a distinct procedural service when billed same day as surgery.

Same Individual Physician or Other Qualified Health Care ProfessionalThe same individual rendering health care services reporting the same Federal Tax Identification number; procedural/pain codes bundled when performed by the Same Individual.

Same Specialty Physician or Other Qualified Health Care ProfessionalPhysicians and/or other qualified health care professionals of the same group and same specialty reporting the same Federal Tax Identification number; certain E/M services not reimbursed when reported by the Same Specialty on same date as anesthesia.

24GCMS 1500 form field 'Days or Units' used to report anesthesia minutes or units on paper claims (02-12 format); anesthesia services must be reported as minutes; units only when code description includes a time period.

Service Unit Count (837P SV104)Electronic claim data element mapping to 24G: 837P loop 2400/SV104 Service Unit Count used to report anesthesia minutes/units on electronic claims.

11/16/2025revised

State Exceptions section: Idaho added.

12/31/2024revised

State Exceptions section: Wisconsin updated.

6/21/2024revised

State Exceptions section: Wisconsin updated; history entries prior to 6/21/2022 archived.

11/05/2024revised

State Exceptions section: Indiana updated.

9/1/2024revised

Reimbursement Formula section updated; State Exceptions updated for multiple states including Indiana, Kentucky, Minnesota, Missouri, New York, North Carolina, Texas, Virginia, and Wisconsin.

2/1/2026revised

Annual review and version update; history entries prior to 2/1/2024 archived.

2/20/2026revisedLatest

Anesthesia Services Bundled into HCPCS Procedural Codes section updated.