Role modifiers AA, AD, QK, QX, QY, or QZ must be reported on anesthesia claims. GC is not a required role modifier.
The formula for anesthesia reimbursement is:
(Base Units + Time Units) * Conversion Factor
Maternity anesthesia reimbursement follows a different structure due to the unique nature of the neuraxial labor analgesia, which does not require continuous personal attendance by the anesthesiologist or CRNA throughout the procedure. Time units for labor management (CPT code 01967), time units are calculated as follows:
- 15-minute increments for the first hour, followed by 30-minute increments for all subsequent hours.
Our health plan reimburses for one anesthesia provider at a time per patient. The only exception is CRNA supervision.
Physical Status Units
No allowance is made by our health plan for physical status, represented by modifiers P1-P6.
Multiple Anesthesia Services
When multiple anesthesia services are performed during a single anesthetic administration, only the anesthesia code with the highest base unit value should be reported. The time reported is the combined total for all procedures.
The only exception to this rule is the anesthesia add-on codes. Anesthesia add-on codes must be billed with the appropriate primary code.
01953 - Each additional 9% total body surface area…
This add-on code is reimbursed to a fee, not using the anesthesia reimbursement formula. The total anesthesia time should be billed to the primary code, 01952.
00851 – Anesthesia for intraperitoneal procedures in lower abdomen including laparoscopy; tubal ligation/transaction
01968 – Anesthesia for cesarean delivery following neuraxial labor anesthetic
01969 – Anesthesia for cesarean hysterectomy following neuraxial labor anesthetic
For codes 01968 and 01969, the primary code is 01967. The formula for anesthesia reimbursement is applied to both the primary and add-on code. Actual anesthesia time for each service should be reported with each CPT code.
Qualifying Circumstances
Qualifying circumstances CPT codes 99100 – 99140 are CMS status B codes and not eligible for reimbursement.
Epidural Management
01996 - Daily hospital management of epidural or subarachnoid continuous drug administration is reimbursed using a fee not using the anesthesia reimbursement formula.
Unlisted Anesthesia Procedure
01999 - Unlisted anesthesia procedure is manually priced according to the policy for unlisted procedure codes. The anesthesia reimbursement formula does not apply.
Reporting
Anesthesia services should be reported using the appropriate codes from the anesthesia section of the CPT manual. Physical status modifiers P1 – P6 may be appended to the anesthesia code when applicable.
Anesthesia time begins when the anesthesiologist begins to prepare the patient for anesthesia care in the operating room or in an equivalent area and ends when the anesthesiologist is no longer in personal attendance, i.e., when the patient is safely placed under post-anesthesia supervision. The time reported should be coded in minutes in the unit’s field of billing format.
Services performed in conjunction with a surgical anesthetic are considered an integral part of that anesthesia service and therefore not eligible for separate reimbursement. These services include but are not limited to:
- Arterial blood gas analysis/monitoring
- Blood pressure monitoring
- Carbon Dioxide Monitoring
- Moderate conscious sedation
- EEG/EKG monitoring
- Evaluation & management services
- Field avoidance
- Heparin analysis
- Intraoperative monitoring
- Esophageal doppler hemodynamic management
- Intubation
- Local anesthesia (for regional or field block)
- Nerve block (except as noted in this policy)
- Oximetry/pulse oximetry
- Patient controlled analgesia.
- Patient position
- Regional IV of local anesthetic
- Supplies and equipment
- Ventilator set-up and/or management
Although some of these services may never be reported on the same date of service as an anesthesia service, many of these services could be provided at a separate patient encounter unrelated to the anesthesia service on the same date of service. Modifiers 59 or XE should be appended under these circumstances.
Postoperative pain management services are generally provided by the surgeon, who is reimbursed under a global payment policy related to the procedure. These services shall not be reported by the anesthesia practitioner unless separate, medically necessary services are required that cannot be rendered, and have been requested, by the surgeon.
Epidural for Postoperative Pain
The pre-operative placement of an epidural catheter for postoperative pain relief is eligible for separate reimbursement to a provider other than the attending surgeon when:
- the epidural catheter is not used as the primary surgical anesthetic, and
- the appropriate epidural catheter code is submitted as a distinct procedural service.
The reimbursement made for the placement of an epidural catheter includes payment for all related professional service(s) on that same date of service, including but not limited to writing orders for medication, services related to the maintenance of the epidural catheter, services related to care of patient’s pain and any injections of an anesthetic substance.
Daily management of an epidural or subarachnoid drug administration (CPT code 01996) is eligible for reimbursement once per date of service for up to three postoperative days beginning the day after the surgery. Charges for four or more days of this service may be reviewed for possible reimbursement. Code 01996 is not eligible for reimbursement on the day the epidural catheter was placed.
Nerve Blocks
An epidural or peripheral nerve block injection for postoperative pain management in patients receiving general anesthesia, spinal (subarachnoid injection) anesthesia, or regional anesthesia by epidural injection may be administered preoperatively, intraoperatively, or postoperatively.
Nerve blocks administered by an anesthesiologist or CRNA as a component of the anesthesia are not eligible for separate reimbursement as they are considered a component of the anesthesia. CPT codes 64400-64530 (Peripheral nerve blocks – bolus injection or continuous infusion) may be reported on the date of surgery if performed for postoperative pain management only if the operative anesthesia is general anesthesia, subarachnoid injection, or epidural injection and the adequacy of the intraoperative anesthesia is not dependent on the peripheral nerve block. Peripheral nerve block codes shall not be reported separately on the same date of service as a surgical procedure if used as the primary anesthetic technique or as a supplement to the primary anesthetic technique. Modifier 59 or XU may be used to indicate that a peripheral nerve block injection was performed for postoperative pain management, rather than intraoperative anesthesia. A procedure note shall be included in the medical record
When eligible for separate reimbursement, the nerve block code should be billed consistent with other non-anesthesia CPT codes and not billed using ASA units (base + time).
Acupuncture
Acupuncture procedure codes when used as an anesthetic are not eligible for reimbursement.
Anesthesia by Surgeon
Moderate sedation is eligible for separate reimbursement to the surgeon if:
- Medicare’s National Correct Coding Initiative (NCCI) does not deny the moderate sedation code as included in the primary procedure.
- Our health plan’s Correct Code Editor (CCE) does not deny the moderate sedation code as included in the primary procedure.
Reimbursement for all other methods of delivering anesthesia will be denied, including but not limited to, nerve blocks, local, topical, and regional anesthesia services, when provided by the same physician performing the medical or surgical service.
Stand-by anesthesia
Stand-by anesthesia or trauma team stand-by anesthesia do not provide direct patient care and therefore are not eligible for separate reimbursement.
References
- 2025 NCCI Manual-Chapter II—Page II-9
- CMS, Anesthesiology Assistants (AAs)
- 42 CFR 69
- American Society of Anesthesiologist, ASA Press. Relative Value Guide® for Anesthesia Values.
- Centers for Medicare and Medicaid Services (CMS). National Correct Coding Initiative Policy Manual for Medicare Services. Chapter II Anesthesia Services CPT Codes 00000-09999.
- Centers for Medicare & Medicaid Services, Medicare Claims Processing Manual, Chapter 12, Section 50 “Payment for Anesthesiology Services.”
- National Correct Coding Initiative Coding Policy Manual for Medicare Services (Coding Policy Manual). Chapter 2.
- Current Procedural Terminology (CPT) Professional Edition. Anesthesia Guidelines.
- AllMed - a company that provides utilization management and independent medical review services that support optimal member outcomes and appropriate utilization.
Cross References
- Adm 101 - Global Days
- Adm 108 - Incidental Procedures
- Adm 129 - Correct Coding Guidelines
- Mod 105 - Modifiers 59, XE, XP, XS, XU; Distinct Procedural Service
