Anesthesia services

Applies to:

Commercial and Medicaid plans

Also see Medicare anesthesia billing, below

Definition

These guidelines cover general, inhalation, regional, peripheral block, spinal, epidural, IV regional block, field block and local anesthesia services, monitored anesthesia care (MAC) and moderate sedation. If appropriate coding, billing or reimbursement guidelines detailed in policy aren't followed, claims may result in a claim denial or recovery of claim payment.

Anesthesia services billing

Payable:

• When reported with either base units and time units or with global fees (see below)

Not payable:

• When the procedure for which anesthesia is administered is non-covered, anesthesia services will not be payable.

• Separate payment for the anesthesia service performed by the physician who also furnishes the medical or surgical service, since the anesthesia service is included in the payment for the medical or surgical service. See the anesthesia modifiers list.
  
  - Anesthesia services are included in the CPT code for surgical service.
  - Modifier 47 would be appended to the surgical CPT code.

• Durable medical equipment and any associated supplies to administer anesthesia when it is needed to perform procedures reimbursed under global fees. (For example: tubing, needles, etc. This is not an all-inclusive list.)

Preventive services, professional and facility claims 

Female sterilization: If sterilization is the only reason for the encounter, report CPT code 00851or 00952 for anesthesia.

Anesthesia services include pre-operative evaluation, administration of anesthetic, medications, blood and fluids, monitoring of the patient and other supportive services:

• The most complex anesthesia service should be billed corresponding to the surgical procedure's anatomical location.
• When the surgical procedure is canceled after the pre-op exam is performed, anesthesia services should not be reported. An evaluation and management service may be reported.

Modifiers

• Physical status modifiers are required for anesthesia services.
• Medical direction and oversight services must be identified with the appropriate QK, QX, QY modifier.
• Anesthesia services performed in part by a resident under direction of a teaching physician should utilize GC modifier.
• Anesthesia services performed personally by the anesthesiologist should be reported with modifier AA.

For additional information on accurate modifier use, see the anesthesia modifiers list.

Multiple Anesthesia Services

Only the most complex anesthesia service should be reported per surgical session. This aligns with ASA billing guidelines. Base units are calculated for the primary procedure and any additional anesthesia procedures will be denied.

If two different providers bill duplicate anesthesia services, only the first submission of that code will be paid.

Exception: Modifiers applied to indicate service performed was medically directed.

• Add-on codes 01953, 01968 or 01969, which are listed separately in addition to the code for the primary procedure
• We don't provide additional reimbursement for unusual positioning even with use of modifier 22.

Post operative pain management services

• Post operative pain management services may be reported by anesthesia provider.
• Documentation must support post op pain management
• Diagnosis associated with post op pain management must be linked to claim line. Example: G89.18 Other acute postprocedural pain

CRNA billing

Base units and time units

Base unit values have been assigned to anesthesia CPT codes by the American Society of Anesthesiologists (ASA). We determine payment for most anesthesia services by both the CPT code base value and the time the service takes. Time units are measured in 15-minute increments.

Reporting anesthesia time units

You must report units on the claim line item (example: 1/2 hour = report two units). The actual time should also be reported on the claim in box 19. (Example: "Service began at 11:30 a.m. and ended at 1:25 p.m.")

• Reporting begins: When induction is initiated, generally within a few minutes of the initiation of the operative session
• Reporting ends: When the patient is transferred to the recovery room and the provider is no longer in personal attendance

Anesthesia services reimbursed based on global fees

Certain procedures are reimbursed based on a global fee rather than base value and time units, including (but not limited to):

• Usual preoperative and postoperative visits
• Administration of fluids
• Anesthesia care during the procedure
• Local anesthesia during surgery
• Monitoring of electrocardiograms (EKGs), pulse, breathing, blood pressure, electroencephalograms, and other neurological monitoring
• Procedures (example: arterial line insertion)
• Monitoring of left ventricular or valve function via transesophageal echocardiogram
• Monitoring of intravascular fluids (IVs), blood administration and fluids used during cold cardioplegia through non-invasive means
• Maintenance of open airway and ventilatory measurements and monitoring.

Qualifying circumstances

Anesthesia procedure or service provided to identify qualifying circumstances (Separate reimbursement is not made for codes below):

• 99100 Anesthesia for patient of extreme age, younger than 1 year and older than 70; *Reference anesthesia services 00326, 00561, 00834, and 00836 to confirm accurate coding
• 99116 Anesthesia complicated by utilization of the total body hypothermia
• 99135 Anesthesia complicated by utilization of controlled hypotension
• 99140 Anesthesia complicated by emergency conditions

Monitored Anesthesia Care (MAC)

Monitored anesthesia care is eligible for coverage when performed by the anesthesiologist, CRNA or qualified anesthetist under the medical direction of a physician. In alignment with CMS, we would follow CMS outlined criteria for billing, coding, and documentation standards for MAC services.

• Monitored anesthesia claims must be reported with modifier QS on claim
• Monitored anesthesia care is reimbursed only to a single provider per day (anesthetist or anesthesiologist)

Moderate Sedation

See moderate sedation guidelines for details.

Priority Health Medicare anesthesia billing

Providers under contract for Priority Health branded Medicare products will be paid according to the contract. These providers should bill according to Medicare rules; general Medicare payment rules apply.

Providers not under contract with Priority Health Medicare Advantage products will be paid according to Medicare payment schedules for the geographic area in which the provider practices.