Commercial and Medicaid plans
Also see Medicare anesthesia billing, below
These guidelines cover general, inhalation, regional, peripheral block, spinal, epidural, IV regional block, field block, and local anesthesia services.
Anesthesia services billing
When reported with either base units and time units or with global fees (see below)
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.
Purchase of durable medical equipment when it is needed to perform procedures reimbursed under global fees
Preventive services, professional and facility claims
Female sterilization: If sterilization is the only reason for the encounter, report CPT code 00581 or 00952 for anesthesia.
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.
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.