Anesthesia billing - full process and Guidelines


Anesthesia Billing Guidelines

Definitions

• Anesthesia - the introduction of a substance into the body by external or internal means that causes loss of sensation (feeling) with or without loss of consciousness.

• Anesthesiologist - a physician (M.D. or D.O.) who specializes in anesthesiology. 


Anesthesiologists are medical doctors who, after obtaining their medical degree and completing their internship, complete an additional 3 years of specialized training in an accredited anesthesiology residency program. They are certified by the American Board of Anesthesiology. As medical doctors, they have a wide range of knowledge about medications, medical care for diseases, how the human body works, and how it responds to the stress of surgery. 


Anesthesia specialists

Anesthesia specialists are responsible for making informed medical decisions to provide comfort and maintain vital life functions while you are receiving anesthesia and in recovery.

Anesthesia specialists include anesthesiologists and qualified nurse or dental anesthetists.

Anesthetist


Most anesthetists are nurses who have graduated from an accredited nurse anesthetist program and who have been certified by the American Association of Nurse Anesthetists to become a certified registered nurse anesthetist (CRNA). Nurse anesthetists are advanced practice nurses with specialized skills in anesthesia administration. A nurse anesthetist is usually supervised by an anesthesiologist or a surgeon, although law and practice may vary by state.

• Certified Registered Nurse Anesthetist (CRNA) - a registered nurse who is licensed by the State in which the nurse practices. The CRNA must be certified by the Council on Certification of Nurse Anesthetists or the Council on Re-certification of Nurse Anesthetists or the CRNA must have graduated within the past 24 months from a nurse anesthesia program that meets the standards of the Council on Accreditation of Nurse Anesthesia Educational Programs and be awaiting initial certification.

• Concurrent Medically Directed Anesthesia Procedures - concurrency is defined with regard to the maximum number of procedures that the physician is medically directing within the context of a single procedure and whether these other procedures overlap each other. The physician can medically direct two, three or four concurrent procedures involving qualified CRNAs.

• Medical Direction - occurs when an anesthesiologist is involved in two, three or four concurrent anesthesia procedures or a single anesthesia procedure with a qualified CRNA. 


Medical Supervision - occurs when an anesthesiologist is involved in five or more concurrent anesthesia procedures.


Personally Performed Anesthesia

We will determine the applicable allowable charge, recognizing the base unit for the anesthesia code and one time unit per 15 minutes of anesthesia time (unless otherwise stated) if:

• The physician personally performed the entire anesthesia service alone;

• The physician is continuously involved in a single case involving a student nurse anesthetist; or,

• The physician and the CRNA are involved in one anesthesia case and the services of each are found to be medically necessary upon appeal. Documentation must be submitted by both the CRNA and the physician to support payment of the full fee for each of the two providers through our appeal process. The physician reports the “AA” modifier and the CRNA reports the “QZ” modifier for a nonmedically directed case. 


Medical Direction

We will determine payment for the physician’s medical direction service on the basis of 60 percent of the allowable charge for the service performed by the physician alone. Medical direction occurs if the physician medically directs qualified CRNAs in two, three or four concurrent cases and the physician performs the following activities that must be documented in the anesthesia record:

• Performs a pre-anesthetic examination and evaluation;

• Prescribes the anesthesia plan;

• Personally participates only in the most demanding procedures in the anesthesia plan, when clinically appropriate;

• Ensures that any procedures in the anesthesia plan that he or she does not perform are performed by a qualified anesthetist;

• Monitors the course of anesthesia administration at frequent intervals;

• Remains physically present and available in the operating room and/or recovery areas for immediate diagnosis and treatment of emergencies; and

• Provides indicated post-anesthesia care.

If the physician is involved with a single case with a CRNA, we will pay the physician service and the CRNA service in accordance with the medical direction payment policy outlined in these guidelines.

If anesthesiologists are in a group practice, one physician member may provide the pre-anesthesia examination and evaluation while another fulfills the other criteria. Similarly, one physician member of the group may provide post-anesthesia care while another member of the group furnishes the other component parts of the anesthesia service. The medical record must indicate that the services were furnished by physicians and identify the physician(s) who furnished them. 

A physician who is concurrently directing the administration of anesthesia to not more than four surgical patients cannot ordinarily be involved in furnishing additional services to other patients. However, addressing an emergency of short duration in the immediate area, administering an epidural or caudal anesthetic to ease labor pain, or periodic, rather than continuous, monitoring of an obstetrical patient, does not substantially diminish the scope of control exercised by the physician in directing the administration of anesthesia to surgical patients. It does not constitute a separate service for the purpose of determining whether the medical direction criteria are met. Further, while directing concurrent anesthesia procedures, a physician may receive patients entering the operating suite for the next surgery, check or discharge patients in the recovery room, or handle scheduling matters without affecting fee schedule payment.

If the physician leaves the immediate area of the operating suite for other than short durations or devotes extensive time to an emergency case or is otherwise not available to respond to the immediate needs of the surgical patients, the physician’s services to the surgical patients are supervisory in nature and would not be considered medical direction. 


Services involving administration of anesthesia should be reported by the use of the Current Procedural Terminology  anesthesia five-digit procedure codes, American Society of Anesthesiologists (ASA) or Procedure surgical codes plus a modifier. HMO Blue Texas and 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  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 HCFA 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 0 unit
P2 A patient with mild systemic disease 0 unit
P3 A patient with severe systemic disease 1 unit
P4 A patient with severe systemic disease that is a constant threat to life 2 unit
P5 A moribund patient who is not expected to survive without the operation 3 unit
P6 A declared brain dead patient whose organs are being removed for donor purposes 0 unit

Filing Claims

Anesthesia services by anesthesiologists or CRNAs must be filed using the appropriate anesthesia Procedure code (beginning with the zero). One of the modifiers listed in this section must be submitted with each anesthesia service billed. Failure to submit one of the modifiers will result in a returned or rejected claim. The allowable charge for medically necessary anesthesia services will be determined based on the applicable anesthesia conversion factor and the modifier submitted on the claim. The applicable anesthesia modifier will determine what percentage of the anesthesia conversion factor is to be applied to each claim, without regard to the order in which claims are received for both  anesthesiologists and CRNAs.

If there are groups from which an anesthesiologist and a CRNA are working together on a case, we will continue to allow a single claim record to contain multiple line items for anesthesia services. We will also accept individual claims for each portion of the anesthesia service performed if more than one provider was involved in the anesthesia case. Each line item must indicate which provider performed the service by identifying the corresponding provider’s NPI on the CMS-1500 claim form in block 24J (or the equivalent field on electronic claims).


To ensure proper reimbursement when billing for anesthesia services, anesthesiologists and CRNAs must include:


1. Number of minutes of administration;

2. Procedure anesthesia (00100-01999) codes with one of the required modifiers listed in this section;

3. American Society of Anesthesiologists’(ASA) modifier code(s) for physical status and Procedure codes appropriate for qualifying circumstances (see further in this section for details), if appropriate;

4. Proper identification by including any performing provider(s) NPI on the claim form.


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”.



Modifier Information Billed by an Anesthesiologist

AA Anesthesia services personally performed by the anesthesiologist
AD Supervision, more than four procedures
QK Medical Direction of two, three or four concurrent anesthesia procedures
QY Medical Direction of one CRNA by an anesthesiologist

Modifier Information Billed by a CRNA

QX Anesthesia, CRNA medically directed
QZ Anesthesia, CRNA not medically directed


Billing Tips

1. Every Procedure has base unit but this has not to be billed in the claims.

2. Enter the time interval in claim notes field or box 19. As per the insurance requirement.

Ex - Start time 19:00 End time 19:30

3. Units has to be calculdated based on the time interval which has to multiplication of 15 Min. For example 0-15 min is calculated as 1 unit and 15 - 30 Min is calculated as 2 Units.

4.If additional Modifier is required enter into the Modifier field.

What Modification required for EMC file

1. EMC file has to go with Minutes instead of units which is we are using on regular billing.

2.we need to mention in 2400 loop segment SV1 03 MJ (Minutes) SV 04 number of minutes.



Data elements needed to calculate payment:

• HCPCS plus Modifier,

• Base Units,

• Time units, based on standard 15 minute intervals,

• Locality specific anesthesia Conversion factor, and

• Allowed amount minus applicable deductions and coinsurance amount.

Formula 1: Calculate payment for a physician performing anesthesia alone

HCPCS = xxxxx

Modifier = AA

Base Units = 4

Anesthesia Time is 60 minutes. Anesthesia time units = 4 (60/15)

Sum of Base Units plus Time Units = 4 + 4 = 8

Locality specific Anesthesia conversion factor = $17.00 (varies by localities)

Coinsurance = 20%

Example 1: Physician personally performs the anesthesia case

Base Units plus time units - 4+4=8

Total units multiplied by the anesthesia conversion factor times .80

8 x $17= ($136.00 - (deductible*) x .80 = $108.80

Payment amount times 115 percent for the CAH method II payment.

$108.80 x 1.15 = $125.12 (Payment amount)

$125.12 x .10 = $12.51 (HPSA bonus payment)

*Assume the Part B deductible has already been met for the calendar year

Formula 2: Calculate the payment for the physician’s medical direction service when the physician directs two concurrent cases involving CRNAs. The medical direction allowance is 50% of the allowance for the anesthesia service personally performed by the physician.

HCPCS = xxxxx

Modifier = QK

Base Units = 4

Time Units 60/15=4

Sum of base units plus time units = 8

Locality specific anesthesia conversion factor = $17(varies by localities)

Coinsurance = 20 %

(Allowed amount adjusted for applicable deductions and coinsurance and to reflect payment percentage for medical direction).

Example 2: Physician medically directs two concurrent cases involving CRNAs Base units plus time - 4+4=8

Total units multiplied by the anesthesia conversion factor times. 50 equal allowed amount minus any remaining deductible
8 x $17 = $136 x .50 = $68.00 -(deductible*) = $68.00

Allowed amount Times 80 percent times 1.15

$68.00 x .80 = $54.40 x 1.15 = 62.56 (Payment amount)

$62.56 x .10 = $6.26 (HPSA bonus payment)


Biling and coding tip for anesthesia CPT codes

CPT Anesthesia Code List

00100–00222 Head

00100 Anesthesia for procedures on salivary glands, including biopsy

00102 Anesthesia for procedures on plastic repair of cleft lip

Coding Tip

Do not use code 00102 for procedures performed on the lip for conditions other than repair of cleft lip. For other, non-cleft lip repairs, see code 00300.

For cleft palate repairs, see 00172.

00103 Anesthesia for reconstructive procedures of eyelid (eg, blepharoplasty, ptosis surgery)

00104 Anesthesia for electroconvulsive therapy


Code 00104 may be denied when multiple electroconvulsive therapy (ECT) is provided. ECT (CPT code 90871) is a noncovered service by Medicare. Therefore, when anesthesia is performed for this reason, it will be denied as such.

00120 Anesthesia for procedures on external, middle, and inner ear including biopsy; not otherwise specified

00124 otoscopy
00126 tympanotomy

Codes 00120–00126 each identify a unilateral service. If the surgeon performs bilateral surgical services, use modifier 50 (bilateral procedure).

00140 Anesthesia for procedures on eye; not otherwise specified
00142 lens surgery
00144 corneal transplant

Codes 00140–00144 each identify a unilateral service. If the surgeon performs bilateral surgical services, use modifier 50 (bilateral procedure).

00145 Anesthesia for procedures on eye; vitreoretinal surgery

Code 00145 is for a unilateral service. If the surgeon performs bilateral surgical services, use modifier 50 (bilateral procedure).

This code is appropriate to use on any vitreoretinal procedures requiring the same anesthetic management.

00160 Anesthesia for procedures on nose and accessory sinuses; not otherwise specified
00162 radical surgery
00164 biopsy, soft tissue

00170 Anesthesia for intraoral procedures, including biopsy; not otherwise specified


PAYMENT AND REIMBURSEMENT - Anesthesia

Payment at Medically Supervised RateOnly three (3) base units per procedure are allowed when the anesthesiologist is involved in rendering more than four (4) procedures concurrently or is performing other services while directing the concurrent procedures. An additional time unit can be recognized if the physician can document he/she was present at induction. Modifier AD is appropriate when services are medically supervised. 

Payment Rules The fee schedule allowance for anesthesia services is based on a calculation that includes the anesthesia base units assigned to each anesthesia code, the anesthesia time involved, and appropriate area conversion factor.

The following formulas are used to determine payment:

• Participating Physician not Medically Directing (Modifier AA)
(Base Units + Time Units) x Participating Conversion Factor = Allowance

• Non-Participating Physician not Medically Directing (Modifier AA)
(Base Units + Time Units) x Non-Participating Conversion Factor=Allowance

• Participating Physician Medically Directing (Modifier QY, QK)
(Base Units + Time Units) x Participating Conversion Factor = Allowance x 50%

• Non-Participating Physician Medically Directing (Modifier QY, QK)
(Base Units + Time Units) x Non-Participating Conversion Factor = Allowance x 50%

• Non-Medically Directed CRNA (Modifier QZ)
(Base Units + Time Units) x Participating Conversion Factor = Allowance

• CRNA Medically Directed (Modifier QX)
(Base Units + Time Units) x Participating Conversion Factor = Allowance x 50%

Anesthesia payment reimbursment tips

PAYMENT AND REIMBURSEMENT - Anesthesia

Payment at Personally Performed Rate

The fee schedule payment for a personally performed procedure is based on the full base unit and one time unit per 15 minutes of service if the physician personally performed the entire procedure. Modifier AA is appropriate when services are personally performed.

Payment at Medically Directed Rate

When the physician is medically directing a qualified anesthetist (CRNA, Anesthesiologist Assistant) in a single anesthesia case or a physician is medically directing 2, 3, or 4 concurrent procedures, the payment amount for each is 50% of the allowance otherwise recognized had the service been performed by the physician alone.

These services are to be billed as follows:

1. The physician should bill using modifier QY, medical direction of one CRNA by a physician or QK, medical direction of 2, 3, or 4 concurrent procedures.
2. The CRNA/Anesthesiologist Assistant should bill using modifier QX, CRNA service with medical direction by a physician.

Payment at Non-Medically Directed Rate

In unusual circumstances, when it is medically necessary for both the anesthesiologist and the CRNA/Anesthesiologist Assistant to be completely and fully involved during a procedure, full payment for the services of each provider are allowed. Documentation must be submitted by each provider to support payment of the full fee.

These services are to be billed as follows:

1. The physician should bill using modifier AA, anesthesia services personally performed by anesthesiologist, and modifier 22, with attached supporting documentation.

2. The CRNA/Anesthesiologist Assistant should bill using modifier QZ, CRNA/Anesthesiologist Assistant services; without medical direction by a physician, and modifier 22, with attached supporting documentation.

Anethesia billing modifier QK, QX AND G8,G9


Anesthesia Billing Update from BCBS WNY


Post-operative Pain Management

When billing for surgical anesthesia (00 series CPT codes) and for post-operative pain management, the codes must appear on the same claim. If billed separately, the claim for the post-operative pain management will be denied due to no preauthorization being on file. 

Billing Guidelines

Anesthesia services CPT CODE should be billed under the rendering providers NPI number using CPT code range 00100 - 01999; there is no separate payment for the supervision of a CRNA Anesthesia modifiers are now required by CMS; we now require them, as well Effective May 15, 2016, claims without the following appropriate modifier will be returned:

AA - Anesthesia services performed personally by anesthesiologist
QX - CRNA with medical direction by a physician
QZ - CRNA without medical direction by a physician

Anesthesia services must be reported as minutes

Any non-anesthesia procedures rendered should continue to be billed using the appropriate surgical or medical CPT code.

Effective October 1, 2015, anesthesia services should be billed using the Current Procedural Terminology (CPT®) code range 00100 - 01999. Operative anesthesia payments are determined by adding base units (the standard base unit value assigned by the American Society of Anesthesiologists) and time units, then multiplying the sum by the anesthesia factor rate:


(Base units + time units) X (anesthesia factor rate) = payment

Time units are based on the length of time required to prepare the patient for anesthesia in the operating room (or equivalent area), administer anesthesia, and through the time when the anesthesiologist's constant personal attendance is no longer required. One time unit is equivalent to 15 minutes. Time units are calculated and rounded  as follows:

For 8 minutes or more - round up (e.g., 1 hour and 9 minutes = 5 time units)

Less than 8 minutes - round down (e.g., 1 hour and 7 minutes = 4 time units)


Additional Anesthesia Information 

• CRNAs must place the name of their supervising doctor in Item 17 of the CMS 1500 or 837P claim form.

• Anesthesia time begins when the provider begins to prepare the patient for induction and ends with the termination of the administration of anesthesia.

• Time spent in pre- or postoperative care may not be included in the total anesthesia time. 

• A surgeon who performs a surgical procedure will not also be reimbursed for the administration of anesthesia for the procedure.

• A group practice frequently includes anesthesiologists and/or CRNA providers. One member may provide the pre-anesthesia examination/evaluation, and another may fulfill other criteria. The medical record must indicate the services provided and must identify the provider who rendered the service. A single claim must be submitted showing one member as the performing provider for all services rendered. In other words, the billing of these services separately will not be reimbursed.

• Anesthesia for arteriograms, cardiac catheterizations, CT scans, angioplasties and/or MRIs should be billed with the appropriate code from the Radiological Procedures subheading in the Anesthesia section of CPT.


• CPT code 00952 (Anesthesia for vaginal procedures…; hysteroscopy and/or hysterosalpingography) pends to Medical Review and must be submitted hardcopy with the anesthesia record attached.

When billed for anesthesia administered during a hysterosalpingogram, CPT code 58340, the documentation attached must indicate:

** medical necessity for anesthesia (diagnosis of mental retardation, hysteria, and/or musculoskeletal deformities that would cause procedural difficulty) and

** that the hysterosalpingogram (HSG) meets the criteria for that procedure (see the Medical Review section-Billing Information)

• Anesthesia for dental restoration should be billed under CPT anesthesia code 00170 with the appropriate modifier, minutes and most specific diagnosis code. Reimbursement is formula-based, with no additional payment being made for a biopsy. A provider does not have to perform a biopsy to bill this code.

• Anesthesia for multiple surgical procedures in the same anesthesia session must be billed on one claim line using the most appropriate anesthesia code with the total anesthesia time spent reported in Item 24G on the claim form. The only secondary procedures that are not to be billed in this manner are tubal ligations and hysterectomies.

• Anesthesia claims with a total anesthesia time less than 10 minutes or greater than 224 minutes must be submitted hard copy with the appropriate anesthesia graph attached.

• Anesthesia claims for multiple but separate operative services performed on the same recipient on the same date of service must be submitted hard copy, with a cover letter indicating the above. The anesthesia graphs from the surgical procedures should be included and the claim with attachments should be submitted to Unisys at the address below.


• When anesthesia claims deny with error codes 749 (delivery billed after hysterectomy was done) or 917 (lifetime limits for this service have been exceeded), a new claim must be submitted to Unisys at the address below with a cover letter describing the situation.


Anesthesia Procedure Codes and Modifiers - Medicaid Guidelines

The Administrative Simplification Requirements of the Health Insurance Portability and Accountability Act (HIPAA) mandate that covered entities adopt the standards for anesthesia Current Procedural Terminology (CPT®1 ) codes. To bill for anesthesia services, providers use anesthesia CPT codes 00100 through 01999 and a physical status modifier that corresponds to the status of the member undergoing the surgical procedure.

Nonanesthesia CPT codes (CPT codes other than 00100–01999) must include an AA modifier to denote that they apply to anesthesia services. These anesthesia services must be billed as a separate line item of the claim form and are reimbursed on a maximum fee basis. For a list of anesthesia-related procedure codes that require the AA modifier, see the Anesthesia Services Codes on the Code Sets page at indianamedicaid.com. Do not bill procedure code 99140 – Anesthesia complicated by emergency conditions (specify) with the AA modifier. Do not use the bilateral procedure code modifier 50 in conjunction with anesthesia modifiers.

For general information about billing and coding, see the Claim Submission and Processing module.

Reimbursement Methodology for Anesthesia Services IHCP pricing calculation for anesthesia CPT codes 00100 through 01999 is as follows:

Base Units
+ 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

Base Units

The IHCP has assigned base unit values to each anesthesia service CPT code (00100–01999). Effective February 1, 2015, the IHCP updated the reimbursement value for anesthesia base units to match 2014 Medicare base units. Note: Providers do not report the base units on claims. The Core Medicaid Management Information System (CoreMMIS) automatically determines the base units for the procedure code as submitted on the claim.

Time Units

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.

Additional Units

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.

• Physical status – Providers should use the appropriate status modifier to denote any conditions described in the modifier descriptions 

Modifier Description Additional Units Allowed

P1 A normal healthy patient 0 units
P2 A patient with mild systemic disease 0 units
P3 A patient with severe systemic disease 1 unit
P4 A patient with a severe systemic disease that is a constant threat to life
2 units
P5 A moribund patient who is not expected to survive without the operation
3 units
P6 A declared brain-dead patient whose organs are being removed for donor purposes
0 units

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 anesthesia 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.

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 Table 3. These claims are subject to postpayment review. 

Modifier Description

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

Anesthesia by Surgeon

Local infiltration, digital block, or topical anesthesia administered by the operating surgeon is included in the surgical reimbursement and no additional benefit is available. IV valium or IV pentothal is a benefit when administered by the surgeon. For obstetrical deliveries, local pudendal and paracervical block anesthesia is included in the obstetrical payment and no additional benefits are allowed for the delivering physician.

Obstetrical Anesthesia

Use modifier 47 with surgical procedure codes to report general or regional anesthesia by the surgeon. Enter units of service as one.

General or regional anesthesia by the delivering physician or an anesthesiologist is reimbursable. Use modifier 47 with delivery procedure codes to report general or regional anesthesia by the delivering surgeon. Enter units of service as one. Epidural anesthesia by a provider other than the delivering practitioner is a covered benefit. Patient contact time must be documented on the claim. Paper claims for more than 120 minutes (eight or more time units) of direct patient contact epidural time require an attached copy of the anesthesia record. Claims may be submitted (no attachments) but documents verifying extended direct patient contact must be maintained and produced upon request.

Standby Anesthesia

Standby anesthesia is a benefit in conjunction with obstetrical deliveries, subdural hematomas, femoral or brachial artery embolectomies, patients with a physical status of 4 or 5, insertion of a cardiac pacemaker, cataract extraction and/or lens implant, percutaneous transluminal angioplasty, and corneal transplant. Unusual circumstances or exceptions to allow a benefit for standby anesthesia for other procedures must be fully documented. Documentation must be submitted with claim.

General Benefits

Surgical reimbursement includes payment for the operation, local infiltration, digital block or topical anesthesia when used, and normal, uncomplicated follow-up care. Under most circumstances, the immediate preoperative visit necessary to examine the patient is included in the surgical procedure whether provided in the hospital or elsewhere.

47 Anesthesia by surgeon Use with surgical procedure codes to report general or regional anesthesia by the surgeon. Local anesthesia is included in the surgical reimbursement.

Anesthesia Services

Anesthesia services must be reported as minutes. Units may only be reported for anesthesia services when the code description includes a time period. Anesthesia time begins when the anesthetist begins patient preparation for induction in the operating room or an equivalent area and ends when the anesthetist is no longer in constant attendance. No additional benefit or additional units are added for emergency conditions or the member’s physica  status.

The fiscal agent converts reported anesthesia time into fifteen minute units. Any fractional unit of service is rounded up to the next fifteen minute increment.

Informed consent requirements

The person obtaining informed consent must be a professional staff member who is qualified to address all the consenting individual’s questions concerning medical, surgical, and anesthesia issues. Informed consent is considered to have been given when the person who obtained consent for the sterilization procedure meets all of the following criteria:

** Has offered to answer any questions that the individual who is to be sterilized may have concerning the procedure
** Has provided a copy of the consent form to the individual
** Has verbally provided all of the following information or advice to the individual who is to be sterilized:
** Advice that the individual is free to withhold or withdraw consent at any time before the sterilization is done without affecting the right to any future care or treatment and without loss or withdrawal of any federally funded program benefits to which the individual might be otherwise entitled
** A description of available alternative methods of family planning and birth control
** Advice that the sterilization procedure is considered to be irreversible
** A thorough explanation of the specific sterilization procedure to be performed

** A full description of the discomforts and risks that may accompany or follow the performing of the procedure including an explanation of the type and possible effects of any anesthetic to be used 

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