Description
This policy is to provide direction on the reimbursement of anesthesia services.
Policy
The following types of anesthesia qualify for reimbursement as anesthesia services when billed by an anesthesiologist, certified registered nurse anesthetist, pain medicine physician, pediatric critical care physician or emergency medicine physician:
1. Inhalation
2. Regional
• Spinal (low spinal, saddle block)
• Epidural (caudal)
• Nerve block (retrobulbar, brachial plexus block, etc.)
• Field block
3. Intravenous
4. Rectal
5. Conscious sedation
Local anesthesia, which is direct infiltration of the incision, wound, or lesion is not a reimbursable service. Local anesthetic is included in the basic service and no additional reimbursement will be allowed.
Reimbursement for anesthesia services is based on the use of relative value units, including base units, plus time units multiplied by a monetary conversion factor. The base units as indicated by the Centers for Medicare & Medicaid Services (CMS) will take precedence over other association’s base unit value when they may be different.
The base value for anesthesia when multiple surgical procedures are performed is the base value for the procedure with the highest unit value. Reimbursement is not allowed for the base unit value of a second, third, etc., procedure.
Anesthesia time begins when the anesthesiologist or Certified Registered Nurse Anesthetists (CRNA) is first in attendance with the patient for creating the anesthetic state. Anesthesia time ends when the anesthesiologist or CRNA is no longer in personal attendance; that is, when the patient may be safely placed under customary postoperative supervision. This time must be documented on the anesthesia record, but not on the claim.
Time must be indicated on all anesthesia claims. Report the actual time spent administering anesthesia as minutes on the claim in the “days or units” block. The Plan will convert total minutes to time units. A “time unit” is a measure of each fifteen (15) minute interval or the actual time reported. Time units are calculated by dividing the total minutes of anesthesia time reported by fifteen (15), rounding to the next whole number.
Anesthesia Services Reported as Units versus Time
Effective April 17, 2020, and thereafter, CPT® codes 01953 is required to be billed as units instead of minutes. Claims submitted as minutes will be denied with an Electronic Claims Preparation (ECP) Edit A3/476.
Modifying Units for Anesthesia Services
Modifying units represent those circumstances that necessitate skills of a physician beyond those usually required.
Qualifying circumstances representative of age, emergency, total body hypothermia, and controlled hypotension should be reported under codes 99100, 99116, 99135 and 99140. These procedures are classified as Status B codes and are not reimbursable.
Physical Status Units
No allowance is made by BCBSND for physical status, represented by modifiers P1-P6.
Position Units
No allowance is made by BCBSND for position units
Anesthesia by Surgeon Modifier 47
BCBSND will not reimburse for anesthesia administered by the physician performing the surgery, the anesthesia is considered inclusive with the surgery.
Effective February 1, 2024, BCBSND will reject claim lines if submitted with modifier 47.
Anesthesia Services Prior to Postponement of Surgery
The following guidelines are used to adjudicate claims for the administration of anesthesia prior to the postponement of surgery:
1. If surgery is cancelled because of the anesthesiologist's preoperative appraisal, reimbursement can be made based on a consultation. (Coverage for consultations is determined according to individual or group customer benefits.)
2. When surgery is aborted after general or regional anesthesia induction has taken place, reimbursement is made based on 3 base units plus time units multiplied by the conversion factor.
3. If anesthesia is reported under a Not Otherwise Classified (NOC)/ Not Otherwise Specified (NOS) code, BCBSND will adjudicate claims for the administration of anesthesia prior to the postponement of surgery, according to policy guidelines.
Modifier 73 – Discontinued out-patient hospital/ambulatory surgery center (ASC) procedure prior to the administration of anesthesia
Note: Anesthesia billed with modifier 73 is not applicable for professional billing and will be denied.
Monitoring Services Performed in Conjunction with the Administration of Anesthesia
The reporting of anesthesia services is appropriate by or under the responsible supervision of a physician. These services may include but are not limited to general, regional, supplementation of local anesthesia, or other supportive services to afford the patient the anesthesia care deemed optimal by the anesthesiologist or CRNA during any procedure. Providers using a sedation scale must ensure the code reported directly reflects the level of sedation provided to the patient in accordance with correct coding.
If monitoring services are reported on the same day as anesthesia, and the charges are itemized, the charges for both services will be combined and only the anesthesia will be reimbursed. Reimbursement for the anesthesia performed on the same date of service includes the allowance for these services and are not eligible as a separate and distinct service. A participating or network provider cannot bill the member separately for these services. If these services are performed independently, report the service with modifier 59.
Examples of monitoring procedures performed while administering anesthesia or for purposes of intraoperative anesthesia management are:
- ECG/EKG monitoring
- Administration of fluids and/or blood
- Respiratory functions (i.e., oxygen saturation [oximetry], end-tidal CO2 monitoring [capnography], etc.)
- Temperature
- Blood Pressure
- Mass spectrometry
Note: Modifier 59 may be reported with a non-evaluation and management E&M service, to identify it as distinct or independent from other non-E&M services performed on the same day. When modifier 59 is reported, the patient’s medical record must support its use in accordance with CPT guidelines.
Direction of Anesthesia Services
The amount for physician anesthesia services is based on allowable base and time units multiplied by an anesthesia conversion factor.
Concurrent directed anesthesia procedures are defined regarding the maximum number of procedures that the physician is directing within the context of a single procedure.
Physicians must report the appropriate anesthesia modifier to denote whether the service was personally performed, directed, or supervised.
The below anesthesia modifiers are allowed by BCBSND to determine appropriate reimbursement:
AA - Anesthesia Services performed personally by the anesthesiologist
QK - Medical direction of two, three or four concurrent anesthesia procedures involving qualified individuals
QS - Monitored anesthesia care service
QX - CRNA service; with medical direction by a physician
QY - Medical direction of one certified registered nurse anesthetist by an anesthesiologist
QZ - CRNA service: without medical direction by a physician
Note: The QS modifier is for informational purposes. Providers must report actual anesthesia time on the claim. Anesthesia services submitted with modifier AD (Medical supervision by a physician: more than four concurrent anesthesia procedures) will not be allowed to receive separate reimbursement.
Payment for Directed Anesthesia
Payment for the physician’s directed service is determined based on our fee schedule and the modifier that is billed on the claim. Direction occurs if the physician directs qualified individuals in one, two, three, or four concurrent cases and the physician performs the following activities:
1. Performs a pre-anesthetic examination and evaluation.
2. Prescribes the anesthesia plan.
3. Personally, participates in the most demanding procedures in the anesthesia plan, including induction and emergence.
4. Ensures that any procedures in the anesthesia plan that he or she does not perform are performed by a qualified anesthetist.
5.. Monitors the course of anesthesia administration at frequent intervals.
6. Remains physically present and available for immediate diagnosis and treatment of emergencies; and
7. Provides indicated-post-anesthesia care
Limitations and Exclusions
While reimbursement is considered, payment determination is subject to, but not limited to:
- Group or Individual benefit
- Provider Participation Agreement
- Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, and medical necessity
- Mandated or legislative required criteria will always supersede.
In instances where the provider is participating, based on member benefits, co-payment, coinsurance, and/or deductible shall apply.
Cross References
History
