Anesthesia Payment & Billing Information
Time and Points Eligible Anesthesia Procedures Defined
Blue Cross and Blue Shield of Texas has determined that certain anesthesia procedures will be reimbursed on time and points methodology.
Procedures that are not included on the Anesthesia Time & Points Eligible List will not be reimbursed using time and points methodology. If a procedure is not on this list, and it is submitted using anesthesia indicators for Time & Points such as:
• using an anesthesia modifier, or
• using time on the claim, or
• if submitted on a non-HIPAA claim format, (Type of Service = 7),
then the provider may receive a denial message for that procedure noting that the service is not eligible for time and points payment methodology.
Services involving administration of anesthesia should be reported by the use of the Current Procedural Terminology (CPT) anesthesia five-digit procedure codes, American Society of Anesthesiologists (ASA) or CPT surgical codes plus a modifier. Blue Cross and Blue Shield of Texas will require that the appropriate anesthesia modifier be filed on anesthesia services.
An anesthesiologist or a CRNA can provide anesthesia services. The anesthesiologist and the CRNA can bill separately for anesthesia services personally performed. When an anesthesiologist provides medical direction to a CRNA, both the anesthesiologist and the CRNA should bill for the appropriate component of the procedure performed. Each provider should use the appropriate anesthesia modifier.
In keeping with the American Medical Association Current Procedural Terminology (CPT) Book, services involving administration of anesthesia include the usual pre-operative and post-operative visits, the anesthesia care during the procedure, the administration of fluids and/or blood and the usual monitoring services (e.g., ECG, temperature, blood pressure, oximetry, capnography and mass spectrometry). Intra-arterial, central venous, and Swan-Ganz catheter insertion are allowed separately.
Payment Calculation Information
Time Units : Time units will be determined by using the total time in minutes actually spent performing the procedure. Fifteen minutes is equivalent to one (1) time unit. Time units will be rounded to the tenth. Therefore, if the procedure lasted 49 minutes, the time units in this example would be 3.26 or 3.3 time units. The units field 24G of the CMS-1500 form should reflect the number of minutes the provider spent on the procedure, (e.g. one hour-thirty minutes should be reflected as (90) in the units field).
Anesthesia time begins when the provider of services physically starts to prepare the patient for induction of anesthesia in the operating room (or equivalent) and ends when the provider of services is no longer in constant attendance and the patient may safely be placed under postoperative supervision.
Base Points : The basis for determining the base points is the Relative Value Guide published by the American Society of Anesthesiologists (ASA). HMO Blue Texas and Blue Cross and Blue Shield of Texas shall implement any yearly update of the Relative Value Guide within 60 days of receipt. Base points used to process claims will be the base points in effect on the date(s) Covered Services are rendered. The exception to this will be Covered Services provided on dates between the receipt of the Relative Value Guide published by ASA and implementation of the updated material.Claims incurred during the exception period will be priced based on the Relative Value Guide in effect on December 1st of the prior calendar year. Newly established codes will be paid at HMO Blue Texas and Blue Cross and Blue Shield of Texas determined rates until the annual update is implemented.
Physical Status Modifiers – to be billed by anesthesiologists and/or CRNAs
P1 A normal healthy person
P2 A patient with mild systemic disease
P3 A patient with severe systemic disease
P4 A patient with severe systemic disease that is a constant threat to life
P5 A moribund patient who is not expected to survive without the operation
P6 A declared brain dead patient whose organs are being removed for donor purposes
Qualifying Circumstances – to be billed by anesthesiologists and/or CRNAs
99100 Anesthesia for patients of extreme age, under 1 year and over 70 (list separately in addition to code for primary procedure)
99116 Anesthesia complicated by utilization of total body hypothermia (list separately in addition to code for primary procedure)
99135 Anesthesia complicated by utilization of controlled hypotension (list separately in addition to code for primary procedure)
99140 Anesthesia complicated by emergency conditions (specify) (list separately in addition to code for primary procedure)
Payment Calculation : Time units plus base points plus unit value(s) allocated to physical status modifiers and/or qualifying circumstances listed above (if applicable) equals “Y”. Allowable amount equals the anesthesia conversion factor multiplied by “Y”.
Reimbursement of OB Anesthesia Add-On Codes 01968 and 01969
When a primary OB delivery anesthesia procedure (01967) is billed with either 01968 and/or 01969, HMO Blue Texas and Blue Cross and Blue Shield of Texas allows a combined maximum of 32 points.
Ventilator Management in Conjunction with Anesthesia Services 94656 and 94657
Ventilation management billed on the same day as an anesthesia procedure is part of the global anesthesia service for the first 24 hours after anesthesia induction and therefore it is not billable.
If procedure code 94656 is reported on the same day, on the same patient, by the same provider as an anesthesia procedure, the
ventilation management service will be denied.
Subsequent ventilation management (94657) billed on the same day as an evaluation and management service is considered part of the evaluation and management service and is not payable separately even if the evaluation and management service is billed with modifier 25. If the patient develops unusual postoperative respiratory problems that require reintubation and/or ventilation management, the physician should report the service with critical care or the appropriate evaluation and management code(s).
Daily Hospital Management of Epidural or Subarachnoid Continuous Drug Administration – 01996
Procedure code 01996 is not allowed on the day of the operative procedure. Only one (1) unit of service (not base units) will be allowed each day, starting on the first day following the surgical procedure, up to a maximum of three (3) days.
62310, 62311, 62318 and 62319
Blue Cross and Blue Shield of Texas has determined that these procedures are surgical services and claims should reflect a type of service of 2. These codes will be reimbursed at the current maximum allowable as determined by HMO Blue Texas and Blue Cross and Blue Shield of Texas. Claims filed with CPT anesthesia procedure code 01991 or 01992 and type of service of 7 will be reimbursed on time and points methodology.
Note: The codes referenced in the information above are subject to changes made by the owner of the code set (i.e. CPT, HCPCS, Revenue Codes, etc).
Anesthesia Time and Calculation of Time Units
Anesthesia time is defined as the period during which an anesthesia practitioner is present with the patient. We consider anesthesia time to begin when the anesthesiologist or CRNA begins to prepare the patient for anesthesia care in the operating room or in an equivalent area and ends when the anesthesiologist or CRNA is no longer in personal attendance, that is, when the patient is safely placed under post-anesthesia supervision.
Anesthesia time must be reported in minutes. Failure to include anesthesia time may result in the claim being either returned or denied. If anesthesia time is reported in units, incorrect payment will result. Minutes will be converted to units by assigning one unit to each 15 minutes of time, or any part of a 15-minute period that anesthesia was administered (exception is Procedure 01967, which is based on a 60-minute unit). No additional time units are payable for add-on codes; therefore, total time must be reported on the primary procedure code. In the case where multiple procedures are performed, time for lower base unit value codes should be reported on the highest base unit value code. Note: We do not recognize time units for Procedure 01996 (see this section for more on Pain Management). The physician who medically directs the CRNA would ordinarily report the same time as the CRNA reports for the CRNA service.
Blue Cross/HMO Louisiana uses the following table to calculate the number of time units:
1 minute to 15 minutes = 1 unit
16 minutes to 30 minutes = 2 units
31 minutes to 45 minutes = 3 units
46 minutes to 60 minutes = 4 units
61 minutes to 75 minutes = 5 units, etc.
According to Procedure guidelines, anesthesia time begins when the anesthetists begins to prepare the patient in the operating room or in an equivalent area and ends when the anesthetist is no longer in personal attendance and the patient may be safely placed under post-anesthetic supervision. Anesthesia time should be reported in minutes. Effective for dates of service on or after January 1, 2014, for all Anesthesiologists, CRNAs and AAs, one unit of time will be allowed for each 15 minute increment of anesthesia or a fraction thereof.
Reimbursement for time based anesthesia is based on the following formulas:
Anesthesia Personally Performed by Anesthesiologist or CRNA (AA or QZ Modifier)
(Base Factor + Total Time Units) x Anesthesia Conversion Factor x Modifier Adjustment = Allowance
Anesthesia Performed under Medical Direction (QK, QX and QY modifiers)
[(Base Factor + Total Time Units) x Anesthesia Conversion Factor] x Modifier Adjustment = Allowance for each provider
Anesthesia “base unit” is the number of units assigned for the anesthetic management of surgical procedures using nationally recognized anesthesia base value standards. Base units are automatically calculated and should not be reported on the claim form. Blue Cross will utilize the CMS base unit values.
Anesthesia time should be submitted on the claim as total minutes. For example, one hour and nine minutes of anesthesia time is billed as 69 minutes. Blue Cross then converts minutes into 15-minute increments. This calculation would be four 15 minute time units and 9/15 of one unit. Total time units for this example are 4.6.
Blue Cross recognizes that the patient must be prepared immediately prior to induction and that some time may be spent immediately after the conclusion of the surgical procedure. Generally, no more than one unit should be necessary to prepare the patient for post-operative transfer to the recovery room. It is inappropriate to bill for anesthesia time while the patient is waiting in a holding area. If it is necessary for a more extensive service to be provided, documentation must be provided in the patient’s medical record to substantiate medical necessity. It is inappropriate to bill time units for services such as administration of blood products or antibiotics in the holding area, when such services could be provided in another area of the hospital or facility.
Reimbursement Methodology for Anesthesia Services
IHCP pricing calculation for anesthesia CPT codes 00100 through 01999 is as follows:
+ Time Units
+ Additional Units for age (if applicable)
+ Additional Unit for emergency or other qualifying circumstances (if applicable)
+ Additional Units for physical status modifiers (as applicable)
× Anesthesia Conversion Factor
= Anesthesia Reimbursement Rate
For anesthesia service codes, providers should indicate the actual duration of the service rendered, in minutes, in field 24G of the CMS-1500 claim form. CoreMMIS calculates the time units, and it allows one unit for each 15-minute period or fraction thereof. (See the Anesthesia for Vaginal or Cesarean Delivery section for special information about time unit calculations for delivery-related anesthesia codes.) Time starts when the anesthesiologist or certified registered nurse anesthetist (CRNA) begins preparing the patient for the procedure in the operating room or other appropriate area. Starting to count time when the preoperative examination occurs is not appropriate. IHCP reimbursement of the preoperative exam is included in the base units. Time ends when the anesthesiologist or CRNA releases the patient to the postoperative unit and is no longer in constant attendance.
CoreMMIS, the claim-processing system, recognizes and calculates additional units for the following:
• Patient age – CoreMMIS applies additional units to the base units for members under 1 year of age or more than 70 years old.
• Emergency conditions (Procedure code 99140) – Additional reimbursement may be added to the rate if CPT codes for emergency (99140 – Anesthesia complicated by emergency conditions) or other qualifying circumstances are also billed. Only one unit of CPT code 99140 is reimbursable for each anesthesia event. Claims billed for two or more units of CPT code 99140 for a single anesthesia event are cut back to one unit for reimbursement. Providers should bill this service on a separate line item of the claim to indicate that the anesthesia provided was complicated by emergency conditions. The maximum reimbursement for one unit of CPT code 99140 is equivalent to two base anesthesia units.
Anesthesia Conversion Factor
The total unit value (which is the sum of time units, base units, and any additional units) is multiplied by the IHCP conversation factor to arrive at the reimbursement rate. Effective for dates of service on or after February 1, 2015, the IHCP anesthesia conversion factor is $16.26, which is 75% of the 2014 Medicare anesthesia conversion factor.
According to Indiana Administrative Code 405 IAC 5-10-3(i), reimbursement is available for medical direction of a procedure involving an anesthetist only when the direction is by an anesthesiologist, and only when the anesthesiologist medically directs two, three, or four concurrent procedures involving qualified anesthetists. Reimbursement is not available for medical direction in cases in which an anesthesiologist is concurrently administering anesthesia and providing medical direction. Anesthesiologists billing for medical direction should use the QK modifier. An anesthesiologist involved in medically directing more than one and up to four procedures cannot be personally performing procedures at the same time. Criteria for medical direction include the following:
• Ensure that only qualified individuals administer the anesthesia.
• Monitor anesthesia at frequent intervals.
• Participate in the most demanding portions of the procedures, including induction and emergence, if applicable.
• Perform the preoperative evaluation.
• Perform the postoperative evaluation.
• Prescribe an anesthesia plan.
• Remain immediately available and not perform other services concurrently
Coverage and Billing for Specific Anesthesia Services
The following sections provide coverage and billing information for particular anesthesia services. Regional Anesthesia (Epidural and Spinal Neuraxial Blocks) When billing regional anesthesia as the anesthesia type for a given surgical procedure that is performed by a qualified anesthesia professional, providers bill regional anesthesia in the same manner as a general anesthetic, such as base units plus time. Regional and general anesthesia are also reimbursed the same way. Providers should bill neuraxial blocks performed as a surgical procedure for the treatment of a condition, such as chronic pain, with the appropriate neuraxial block code, quantity of one, with no anesthesia modifier.
Anesthesia for Vaginal or Cesarean Delivery
Providers billing anesthesia services for labor and delivery use the anesthesia CPT codes for vaginal or cesarean delivery. Billing for obstetrical anesthesia is the same as for any other surgery, regardless of the type of anesthesia provided (such as general or regional), including epidural anesthesia. When the anesthesiologist starts an epidural for labor, and switching to a general anesthetic for the delivery becomes necessary, combine and bill the total time for the procedure performed, such as vaginal delivery or cesarean section (C-section).
CoreMMIS calculates total units by adding base units to the number of time units, which are calculated by the system based on the number of minutes billed on the claim. CoreMMIS converts each 15-minute block of time to one time unit. However, for procedure codes 01960 – Anesthesia for vaginal delivery only and 01967 – Neuraxial labor analgesia/anesthesia for planned vaginal delivery (this includes any repeat subarachnoid needle placement and drug injection and/or any necessary replacement of an epidural catheter during labor), CoreMMIS calculates one time unit for each 15-minute block of time billed in the first hour of service and, for subsequent hours of service, calculates one unit of service for every 60-minute block of time or portion billed. When a provider other than the surgeon or obstetrician bills for epidural anesthesia, the IHCP reimburses that provider in the same manner as for general anesthesia.
Monitored Anesthesia Care
The IHCP allows payment for medically reasonable and necessary monitored anesthesia care (MAC) services on the same basis as other anesthesia services. To identify the services as MAC, providers must append an appropriate modifier to the appropriate CPT code, in addition to other applicable modifiers.
Appropriate MAC modifiers include the following:
• QS – Monitored anesthesia care services
• G8 – Monitored anesthesia care (MAC) for deep complex, complicated, or markedly invasive surgical procedure
• G9 – Monitored anesthesia care (MAC) for a patient who has a history of severe cardiopulmonary condition
MAC also includes the performance of a preanesthestic examination and evaluation; prescription of the anesthesia care required; administration of any necessary oral or parenteral medications, such as Atropine, Demerol, or Valium; and the provision of indicated postoperative anesthesia care.
Regional Anesthesia (Epidural and Spinal Neuraxial Blocks)
When billing regional anesthesia as the anesthesia type for a given surgical procedure that is performed by a qualified anesthesia professional, providers bill regional anesthesia in the same manner as a general anesthetic, such as base units plus time. Regional and general anesthesia are also reimbursed the same way. Providers should bill neuraxial blocks performed as a surgical procedure for the treatment of a condition, such as chronic pain, with the appropriate neuraxial block code, quantity of one, with no anesthesia modifier.
Postoperative Pain Management Services
The IHCP reimburses for postoperative epidural catheter management services using CPT code 01996. The IHCP does not pay separately for CPT code 01996 on the same day the epidural is placed. Rather, providers should bill this code on subsequent days when the epidural is actually being managed. Providers should use this code for daily management of patients receiving continuous epidural, subdural, or subarachnoid analgesia. The IHCP limits this procedure to one unit of service for each day of management. CPT code 01996 is only reimbursable during active administration of the drug. Providers should not append a modifier when this procedure is monitored by an anesthesia provider. Postoperative pain management codes, when submitted with an anesthesia procedure code and performed on the same day as surgery, must be billed in conjunction with the most appropriate modifier listed in
59 Distinct procedural service
XE Separate encounter; a service that is distinct because it occurred during a separate encounter
XP Separate practitioner; a service that is distinct because it was performed by a different practitioner
XS Separate structure; a service that is distinct because it was performed on a separate organ/structure
XU Unusual non-overlapping service; the use of a service that is distinct because it does not overlap usual components of the main service