Anesthesia Services, Professional And Facility

Description

Anesthesia services include all services typically associated with the administration and monitoring of analgesia or anesthesia in order to produce partial or complete loss of sensation and/or consciousness. For purposes of this reimbursement policy, anesthesia services include general anesthesia and regional anesthesia.

Blue Cross Blue Shield North Carolina (Blue Cross NC) uses several factors in determining reimbursement for anesthesia care, including but not limited to: base units, time units, conversion factors, and modifiers. Claims may be processed according to same provider or same group practice. Same group practice is defined as a physician and/or other qualified health care professional of the same specialty with the same Federal Tax ID number.

Policy

Blue Cross NC will allow reimbursement for anesthesia services according to the criteria outlined in this policy, unless modified or superseded by contractual language.

Reimbursement Guidelines

Blue Cross NC reimbursement is time-based, determined by the Blue Cross NC reimbursement formula and applicable modifiers.

Anesthesia Reimbursement Formula

Blue Cross NC anesthesia reimbursement is based on an anesthesia reimbursement formula:

(Base Units + Time Units) X Conversion Factor = Allowance

Blue Cross NC applies the base unit as assigned by the American Society of Anesthesiologists (ASA) to the reported anesthesia procedure code. Time units are calculated by dividing the reported anesthesia time total minutes by 15. Conversion factor (CF) is an incremental multiplier rate defined by specific contracts or industry standards.

Providers must report anesthesia time in one (1) minute increments. Anesthesia time is considered the continuous time of provider personal attendance between start and stop of the anesthesia service. Anesthesia time starts when member preparation for anesthesia administration begins, and it ends when the provider is no longer in personal attendance (i.e., member can be safely placed under postoperative care).

Anesthesia Modifiers

Blue Cross NC requires the appropriate use of anesthesia modifier(s) to identify who performed the anesthesia service and their involvement – personally performed, medically directed or medically supervised. Anesthesia modifiers indicating who performed the service (performed/medical direction/supervision modifiers) must be submitted in the first modifier position, followed by the physical status modifiers.

It is not appropriate to bill multiple anesthesia modifiers on the same claim line, as they are considered mutually exclusive with exception of Modifier QS. If an anesthesia service changes from the highest level of ‘personally performed’ to ‘medical direction’ or the lowest level of ‘medical supervision’, the anesthesia modifier should reflect the lowest level of involvement provided during the service.

Anesthesia modifiers are indicated below:

Anesthesia Modifiers

AA Anesthesia services performed personally by an anesthesiologist

AD* Medical supervision by a physician: more than 4 concurrent anesthesia procedures

QK Medical direction of 2, 3, or 4 concurrent anesthesia procedures involving qualified individuals

QS Monitored Anesthesia Care (MAC) services (can be billed by a qualified nonphysician anesthetist or a physician)

QX Qualified nonphysician anesthetist with medical direction by a physician

QY Medical direction of one qualified nonphysician anesthetist by an anesthesiologist

QZ CRNA service: without medical direction by a physician

*Modifier AD will allow only three base units per procedure when the anesthesiologist is involved in furnishing more than four procedures concurrently or is performing other services while directing the concurrent procedures. One additional base unit may be recognized on appeal if the physician documents their presence at induction.

Physical Status Modifiers

Blue Cross NC does not allow additional reimbursement for physical status modifiers. Physical status modifiers are informational only.

Multiple General Anesthesia Services

Blue Cross NC only allows reimbursement for one anesthesia procedure per date of service. When multiple general anesthesia services are performed on the same date of service, only the procedure with the highest base value should be reported, in addition to the time for all anesthesia services combined.

Anesthesia for Pain Management Injections

Under most routine circumstances, minor pain management procedures, including but not limited to, epidural steroid injections, trigger point injections, and epidural blood patch, only require local anesthesia. For adults, an accompanying surgical procedure (other than a pain management procedure) must also be present on the claim for the associated anesthesia and moderate sedation service to be eligible for reimbursement.

Surgical Pain Blocks

When surgical pain blocks are placed before induction or after emergence, the time spent placing the block is not reimbursable as an anesthesia service and is not eligible to be added to the reported anesthesia time.

Anesthesia Supplies

Regardless of place of service, Blue Cross NC considers anesthesia supplies incidental to the anesthesia service codes (00100 - 01999) and will not be eligible for separate reimbursement.

Conscious or Moderate Sedation

Blue Cross NC does not allow separate reimbursement for local anesthesia or for anesthesia administered by the operating surgeon, surgical assistant, or dentist. This is considered incidental to the surgical or dental procedure. This includes sedation given for endoscopic procedures including colonoscopy.

Note: Dental anesthesia must be reported using the appropriate ADA dental anesthesia code, not as an anesthesia CPT procedure.

Obstetrical Anesthesia

Blue Cross NC reimburses the following obstetrical anesthesia services at a flat rate and considers these services to be non-timed procedures:

• Anesthesia for vaginal delivery
• Neuraxial labor analgesia/anesthesia for planned vaginal delivery
• Daily hospital management of epidural or subarachnoid continuous drug administration

Anesthesia performed/medical direction/supervision modifiers are required to be reported with the service (refer to the Anesthesia Modifiers section, above).

Rationale

Anesthesia services as defined in this policy will be reimbursed consistent with guidance from CMS, expert medical society standards as set forth herein and in accordance with correct coding guidelines.

Billing and Coding

Applicable codes are for reference only and are not all inclusive. For further information on reimbursement guidelines, please see the Blue Cross NC web site at Blue Cross NC. 

Related policy

Anesthesia Services (Medical Policy)

Bundling Guidelines

Guidelines for Global Maternity Reimbursement

Modifier Guidelines

Pricing & Adjudication Principles

Spinal Manipulation under Anesthesia (Medical Policy)

References

American Society of Anesthesiologists (ASA) and ASA Relative Value Guide

Healthcare Common Procedure Coding System

American Medical Association, Current Procedural Terminology (CPT®)

Centers for Medicare & Medicaid Services

History

6/1/2022 New policy developed. Medical Director approved. Notification on 3/31/2022 for effective date 6/1/2022.

8/1/2022 “Anesthesia Supplies” added to Reimbursement Guidelines section. Notification on 6/1/2022 for effective date 8/1/2022.

12/31/2022 Routine Policy Review. Minor revisions only.

4/1/2024 Clarifying updates made to Reimbursement Guidelines. Added language to update Modifier AD reimbursement rates and post-surgical pain blocks. “Monitored Anesthesia” removed from Reimbursement Guidelines. Medical Director approved. Notification on 2/1/2024 effective 4/1/2024 (ss)

10/01/2024 Added language to update physical status modifiers, disallowing additional reimbursement. RPOC approved. Notification on 08/01/2024 and effective 10/01/2024 (ss)

11/1/2024 Clarification to the definition of same group practice. No change to policy intent. (tlc)

Application

These reimbursement requirements apply to all commercial, Administrative Services Only (ASO), and Blue Card Inter-Plan Program Host Members (other Blue Cross and/or Blue Shield Plan Members who seek care from the NC service area). This policy does not apply to Blue Cross NC Members who seek care in other states.

This policy relates only to the services and/or supplies described herein. Please refer to the applicable Member's Benefit Booklet for availability of benefits. Member's benefits may vary according to benefit design; therefore, Member benefit language should be reviewed before applying the terms of this policy.