Services are provided by a qualified anesthesia provider to a surgical patient while in a state of analgesia or anesthesia so that surgical intervention can be undertaken. Anesthesia services consist of the administration of an anesthetic agent, typically by injection or inhalation, causing partial or complete loss of sensation, with or without loss of consciousness.
The anesthesia procedure is administered by a qualified anesthesia provider, which includes:
• Anesthesiologist (other than the operating physician, assistant surgeon, or obstetrician)
• Anesthesiologist Assistant AA
• Certified Registered Nurse Anesthetist (CRNA)
• Physicians qualified to administer general anesthesia or to appropriately supervise anesthesia professionals
• Usual preoperative and postoperative visits
• Anesthesia care during the procedure
• Administration of fluids or blood
• Usual monitoring (e.g., ECG, temperature, blood pressure, oximetry, capnography, mass spectrometry) as defined by American Society of Anesthesiologists ( ASA) and/or CPT guidelines.
According to CPT guidelines, the reporting of anesthesia services is appropriate by or under the responsible supervision of an anesthesiologist. These services may include but are not limited to general, regional, supplementation of local anesthesia, or other supportive services in order to afford the patient the anesthesia care deemed optimal by the anesthesiologist during any procedure.
Non-Covered Services
Services not covered under the terms of the member’s applicable Benefit Agreement include, but are not limited to, the following:
• Standby anesthesia – Florida Blue does not cover physicians “standing by” in anticipation of needing general anesthesia
• Anesthesia administered by operating physician or surgical resident
• Anesthesia by hypnosis
• Anesthesia by acupuncture
• Anesthesia for cosmetic surgery
Monitored Anesthesia Care
Intra-operative monitoring by an anesthesiologist, physician, or other qualified individual under the medical direction of the anesthesiologist, of the patient’s vital physiological signs in anticipation of the need for administration of general anesthesia or of the development of adverse physiological patient reaction to the surgical procedure.
Qualified anesthesia providers may bill Florida Blue directly for services using the anesthesiology codes 00100 – 01999. While some CPT surgical codes are appropriate to use when billing anesthesia services (e.g., 36620); the majority of anesthesia services should be billed using codes in the range of 00100 – 01999.
Qualifying Circumstances
Reimbursement for qualifying circumstances for anesthesia (99100-99140) is included in the basic allowance for other anesthesia procedures (00100-01999) when performed on the same day by the same physician. No additional reimbursement is allowed for CPT codes 99100-99140.
Moderate Sedation
Florida Blue separately allows moderate sedation provided by the same physician performing the diagnostic or therapeutic service that the sedation supports, with procedures 99143-99145 except as follows:
• 99143-99145 will not be separately reimbursed with any procedures in Appendix G (refer to Summary of CPT Codes That Include Moderate (Conscious) Sedation) based on CPT guidelines.
• 99143-99145 will not be separately reimbursed with CPT and HCPCS procedures whose verbiage contains “with anesthesia,” “under anesthesia,” “under or requiring general anesthesia,” etc. based on their verbiage and the fact that moderate sedation is not expected with these procedures.
• 99143-99145 will not be separately reimbursed when billed with radiation therapy services, based on the National Correct Coding Initiative that contains edits bundling CPT codes 99143-99144 into all radiation therapy services.
Procedure codes 99148-99150 should be used if a second physician other than the healthcare professional performing the diagnostic or therapeutic services provides the moderate sedation.
Medical Direction
• Only anesthesiologists will be reimbursed for medical direction.
• The anesthesiologist must be physically present in the operating suite to bill for direction of concurrent anesthesia
procedures.
• Medical direction is defined as:
* * Performing a pre-anesthetic examination and evaluation;
* * Prescribing the anesthesia plan;
* * Personally participating in the most demanding procedures in the anesthesia plan, including induction and emergence:
* * Ensuring that any procedures in the anesthesia plan that he/she does not perform are rendered by a qualified individual;
* * Monitoring the course of anesthesia administration at frequent intervals;
* * Remaining physically present and available for immediate diagnosis and treatment of emergencies; and
* * Providing the indicated post-anesthesia care.
• The anesthesiologist may bill for the direction of up to four concurrent anesthesia procedures for straight Medicaid recipients.
• Reimbursement will not be made for the direction of five or more anesthesia procedures being performed concurrently unless the patient is a Medicare/Medicaid beneficiary.
Reimbursement Formulas for Surgical Anesthesia
The formulas for determining payment for surgical procedures requiring anesthesia are as follows:
• Anesthesia performed personally by the anesthesiologist (AA)
Base units plus time units times conversion factor = X – 20% = fee.
• Medical direction of 2, 3 or 4 concurrent anesthesia procedures by anesthesiologist (QK)
Base units plus time units times conversion factor = X – 50% = Y – 20% = fee.
• Medical direction of one CRNA by an anesthesiologist (QY)
Base units plus time units times conversion factor = X – 50% = Y – 20% = fee.
• CRNA service with medical direction by an anesthesiologist (QX)
Base units plus time units times conversion factor = X – 50% = Y – 20% = fee.
• Anesthesia performed by the CRNA without medical direction (QZ)
Base units plus time units times conversion factor = X – 20% = fee.
• In billing for anesthesia for second and third degree burn excision or debridement with or without skin grafting, report the total anesthesia time with code 01952 and report the appropriate number of units of body surface area with code 01953.
* * Reimbursement for code 01952 will be as follows:
Base units of 01952 plus time units for 01952 and 01953 (1 = 15 minutes) times conversion factor ($16.41) = X – 20% = fee.
* * Reimbursement for code 01953 will be:
One base unit for each unit of 01953 times the conversion factor ($16.41) = X -20% = fee. For 01953 only, report units instead of time in Item 24G.
