Notification

Reporting and Documentation Requirements for Anesthesia Services


Notification Issue Date: 01/22/2020

This version of the policy will become effective 04/20/2020. The following criteria have been added to the policy:

  • Performance and oversight of Medical Direction
  • Requirements and criteria for a non-anesthesia provider performing anesthesia AND administering anesthesia
  • Clarification on reporting anesthesia for providers (time and modifier reporting)
  • Expanded and clarified language in regards to reporting of multiple anesthesia procedures
  • Billing requirements for surgeons performing anesthesia and surgical procedures
The Company's coverage of Moderate Sedations has changed to reflect American Medical Association and CMS guidelines.

The Company's reimbursement position for preoperative consultations and E & M services has changed from eligible for reimbursement to not eligible for separate reimbursement.

The Company's reimbursement position has changed from considering combined time of each anesthesia service performed to total time anesthesia administration

Criteria and reporting instructions added for preoperative services and discontinued anesthesia services added from archived policies:
01.00.08c Preoperative Consultations Performed by Providers in Anesthesia Specialties
01.00.02b Anesthesia Services for a Cancelled or Discontinued Procedure


Claim Payment Policy


Title:Reporting and Documentation Requirements for Anesthesia Services

Policy #:00.01.14r


Application of Claim Payment Policy is determined by benefits and contracts. Benefits may vary based on product line, group or contract. Medical necessity determination applies only if the benefit exists and no contract exclusions are applicable. Individual member benefits must be verified.

In products where members are able to self-refer to providers for care and services, members are advised to use participating providers in order to receive the highest level of benefits.When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.

For more information on how Claim Payment Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



Policy

COVERED ANESTHESIA SERVICES


ANESTHESIA SERVICES PERFORMED BY ANESTHESIA PROVIDERS
Anesthesia services (including Monitored Anesthesia Care [MAC]) performed by an anesthesia provider (i.e., anesthesiologist, certified registered nurse anesthetist [CRNA]), in conjunction with a medically necessary procedure(s) or service(s), are covered and eligible for reimbursement consideration by the Company when the services are reported in accordance with this policy and the appropriate documentation is included on the claim and the individual's medical record.

Medical direction by an anesthesiologist is covered and eligible for reimbursement consideration by the Company when all the following requirements are met:

  • An anesthesiologist has prescribed the anesthesia plan.
  • The anesthesiologist is NOT medically directing more than four anesthesia procedures concurrently.
  • The anesthesiologist is physically present or immediately available in the operating suite.
  • The anesthesiologist monitors the course of anesthesia at frequent intervals.
  • It is documented that the anesthesiologist performed the preoperative, preanesthetic and postoperative evaluations.

ANESTHESIA SERVICES PERFORMED BY NON-ANESTHESIA PROVIDERS
Moderate sedation services performed by a professional provider are covered and eligible for reimbursement consideration by the Company when the services are reported in accordance with this policy and the appropriate documentation is included on the claim and the individual’s medical record.

Anesthesia and sedation (i.e., moderate sedation and deep sedation) services performed by a professional provider in an oral surgery specialty, when performed for covered dental or oral surgery procedures, are covered and eligible for reimbursement consideration by the Company. Anesthesia performed for non-covered dental or oral surgery procedures may be covered and eligible for reimbursement consideration in accordance with applicable Company policies and federal and/or state mandates (Refer to Policy entitled: Reimbursement for Associated Services Performed in Conjunction with Dental Care).

Epidural anesthesia services performed by an obstetrician or obstetrician/gynecologist, when performed for maternal labor pain analgesia, are covered and eligible for reimbursement consideration by the Company.

NON-COVERED ANESTHESIA SERVICES

Anesthesia services performed by professional providers other than those described above are considered non-covered and therefore not eligible for reimbursement consideration by the Company.

Anesthesia services performed in conjunction with non-covered procedures are not covered with the exception of those anesthesia services defined in applicable Company policies or mandated by federal and/or state law.

REPORTING AND DOCUMENTING ANESTHESIA SERVICES

TIME-BASED ANESTHESIA SERVICES
Unless otherwise noted, anesthesia services are reported in minutes using the following criteria:
  • Providers should report total minutes of anesthesia with the appropriate anesthesia procedure code.
    • If the anesthesia service is discontinued, after the induction of regional or general anesthesia, the total number of minutes that anesthesia was administered should be reported.
    • If the anesthesia service is interrupted for a short duration, the total number of minutes that anesthesia was administered should be reported, less the number of minutes representing the interruption.
  • The Company applies the following standard formula to calculate and determine allowance and reimbursement for eligible anesthesia services reported in minutes:
    • Time Unit(s) + Base Units x Conversion Factor = Allowance
    • Time Units: The company calculates the reported time of anesthesia in minutes divided by 15 (rounded to one decimal place) to determine the time in units.
    • Base units should not be reported with an anesthesia procedure code. The Company calculates reimbursement using the Centers for Medicare & Medicaid Services (CMS) anesthesia base units.
  • Modifier AA must be reported when it is medically necessary for the anesthesiologist to be completely and fully involved during a procedure. The payment amount for the service is 100 percent of the calculated allowance.
  • Modifier QZ must be reported when it is medically necessary for the medically directed qualified nonphysician anesthetist or CRNA to be completely and fully involved during a procedure without medical direction by an anesthesiologist. The payment amount for the service of each is 100 percent of the calculated allowance.
  • Modifier AD, QK, QX, or QY must be reported when a single anesthesia procedure involves both a physician medical direction service and the service of the medically directed qualified nonphysician anesthetist. The payment amount for the service of each is 50 percent of the calculated allowance.
  • The appropriate medical direction modifier is reported in conjunction with the appropriate anesthesia procedure code.
  • Modifier QS is reported as a secondary modifier indicating Monitored Anesthesiology Care Services (MACS) by a physician or qualified non-physician anesthetist. The modifier is reported for informational purposes only and professional providers must report the anesthesia time and one of the above payment verification modifiers.
  • Modifier GC is reported as secondary modifier indicating a service performed by a resident under direction of a teaching physician. The modifier is reported for informational purposes only and must be reported in conjunction with one of the above payment verification modifiers.
  • Modifier 47 is reported with a non-anesthesia procedure code to indicate anesthesia services (regional or general) were performed by the professional provider who also performed the surgical procedure.
  • Physical status modifiers (P1 through P6) are informational only and not eligible for additional reimbursement when reported.

NON-TIME-BASED ANESTHESIA SERVICES
The following anesthesia services, when reported, have either a Flat Rate or are reported in units rather than minutes.
  • The following anesthesia codes are not based on time and, when eligible, are reimbursed at a flat rate: 01960, 01967, 01996.
  • The following dental anesthesia codes, when eligible, are reimbursed in units: HCPCS codes D9222, D9223, D9239, D9243.
  • Procedure code 01953 is reimbursed in units.
    • When reported with the appropriate primary code (01952), the burn debridement anesthesia add-on code (01953) is eligible for separate reimbursement consideration.
    • The total time (in minutes) of the anesthesia administrated is reported with the primary code (01952). No Time should be reported with the add-on code (01953).

CANCELLED ANESTHESIA SERVICES
Anesthesia services performed in conjunction with a cancelled covered procedure, before induction of regional or general anesthesia, are covered and eligible for reimbursement consideration by the Company. The professional provider should report the appropriate time-based Evaluation & Management (E & M) code for the examination only.

ANESTHESIA FOR MULTIPLE PROCEDURES
Anesthesia administered for multiple covered procedures performed during the same operative session is covered and eligible for reimbursement consideration. Providers must report only the anesthesia procedure with the highest base unit, with the exception of procedure codes identified as “add-on” codes (01953, 01968, 01969).The total time of anesthesia administration for the procedures should also be reported in the same line of the anesthesia procedure code with the highest base unit. However, do not report time for anesthesia codes that are identified in this policy as not eligible to be reported in minutes.

ANESTHESIA SERVICES NOT ELIGIBLE FOR SEPARATE REIMBURSEMENT

The Company considers the following services to be an integral part of basic anesthesia service and are, therefore, not eligible for separate reimbursement consideration as they are furnished under and reported in the base unit value for the anesthesia service. These services include, but are not limited to, the following:
  • Preoperative consultations and evaluations performed the day before or day of the procedure. Preoperative consultations and evaluations involve but are not limited to:
    • A face-to-face consultation between the anesthesia specialist and patient
    • Sufficient history and examination of the patient
    • Evaluation for risk of adverse reactions
    • Alternative approaches to planned anesthesia
    • Address questions and consult patient regarding anesthesia procedure
  • The preanesthetic evaluation of the individual, which is routinely performed immediately prior to anesthesia administration and surgery
  • Preparation for and the administration of anesthesia medications
  • Administration of fluids and/or blood
  • Routine monitoring (e.g., temperature, oximetry, electrocardiogram [ECG/EKG], blood pressure, capnography, mass spectrometry)
  • Postoperative evaluation and management related to the surgery
    • Management of epidural or subarachnoid drug administration (procedure code 01996) is eligible for separate reimbursement consideration on dates of service subsequent to the surgery, not on the date of surgery.
    • Management of epidural or subarachnoid drug administration (procedure code 01996) should be billed once per day as a single unit for each day that the individual receives anesthesia.
  • Sedation administered prior to or to facilitate induction or as part of covered MAC services.
  • Moderate sedation administered in a non-facility setting by a professional provider other than the professional provider performing the diagnostic or therapeutic services.
  • Qualifying circumstances (procedure codes 99100, 99116, 99135, and 99140)
    • These are always bundled procedure codes.
    • Refer to the Always Bundled Procedure Codes policy.

The Company considers the following services to be an integral part of a surgical service and are, therefore, not eligible for separate reimbursement consideration:
  • Local anesthesia, topical anesthesia and all other sedation at a lower level than Moderate Sedation services.
  • Anesthesia services performed by the same professional provider who performs the surgical service.
    • Modifier 47 must be appended to the surgical procedure code.
    • No anesthesia procedure codes should be reported.

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to, the following: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports. Additionally, the medical record must clearly document who administered the anesthesia, the time minutes (including any interruptions to the administration of the anesthesia), and any other documentation requirements listed in this policy.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.

BILLING REQUIREMENTS

Inclusion of a code in this policy does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply
Guidelines

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, anesthesia services may be covered under the medical benefits of the Company’s products.

Global surgery rules do not apply to the procedure codes representing the administration of anesthesia.

BILLING GUIDELINES

Professional providers should report only the anesthesia procedure performed and, if appropriate, the total number of minutes. The company will apply all base and time unit conversion factors.

A modifier should be appended to all reported anesthesia procedure codes
  • All anesthesia procedures must reported with a payment verification modifier
  • If an informational modifier (e.g. QS, GC) is reported with an anesthesia procedure it must also be reported with a payment verification modifier, as communicated in this policy.
    Description

Anesthesia is the partial or complete depression of sensation (analgesia) with or without loss of consciousness as a result of the administration of an anesthetic agent. There are three major categories of anesthesia:
  • General anesthesia may be administered via inhalation of a vapor or gas and/or via injection of a liquid to attain insensitivity to pain, amnesia, and unconsciousness, characterized by a partial or complete loss of protective reflexes, the inability to independently maintain an airway, and the inability to respond purposefully to commands.
  • Regional anesthesia, which is divided into spinal, saddle, epidural, caudal, and nerve blocks, uses a local anesthetic injected into a specific body region to attain insensitivity and limited or total immobility, while maintaining the individual's consciousness.
  • Local (or topical) anesthesia uses an anesthetic agent to interrupt the initiation and transmission of nerve impulses, thereby resulting in numbness or loss of sensation in an area.

Medical direction is the supervision of anesthesia as direction, management, or instruction by an anesthesiologist who is physically present or immediately available in the operating suite. An anesthesiologist who provides medical direction does not actually administer anesthesia but must be available to provide anesthesia or perioperative intervention if required.

Monitored anesthesia care (MAC) is the intraoperative monitoring by a provider in an anesthesia specialty if an individual’s vital physiological signs in anticipation of either the need for general anesthesia and/or the development of an adverse physiological reaction to the surgical procedure (e.g., hypotension). This monitoring includes the following: an evaluation of the patient's oxygenation, ventilation, circulation, and temperature; a preanesthetic examination and evaluation; prescription of the anesthesia care required; administration of any necessary oral or parenteral medications (e.g., sedation and analgesia medications); and the provision of postoperative anesthesia care.

Sedation involves the use of central nervous system (CNS)--depressing medications to obtain a calmed and medically controlled mental state. The level of CNS suppression varies with the type and dose of medication administered.
  • Moderate sedation, also referred to as conscious sedation, is the administration of moderate sedation/analgesia to achieve a medically controlled state of depressed consciousness while minimizing the individual's discomfort utilizing pain relievers and sedatives. The individual's airway, protective reflexes, and ability to respond to stimulation or verbal commands are maintained.
  • Deep sedation is a drug induced depression of consciousness during which individuals cannot be easily aroused but may respond following repeated or painful stimulation. Individuals may require assistance in maintaining a patent airway, and spontaneous ventilation may be inadequate. Cardiovascular function is usually maintained.

Generally, most anesthesia administration services are reported using the American Society of Anesthesiologists (ASA) procedure codes. However, there are other procedure codes available to represent dental anesthesia, infusions, injections for pain, local/topical analgesia, and sedation services that are outside of the ASA procedure code range.

Anesthesia time is used as part of the formula for determining the reimbursement for most anesthesia services. Anesthesia time is a continuous time period, in minutes, from the time the anesthesia provider initiates preparation of the patient for anesthesia care in the operating room or equivalent area, until the time when the anesthesia provider is no longer in personal attendance (i.e. when the patient may be placed safely under postoperative supervision). One-time unit is applied to each 15-minute increment.

Anesthesia base units are the value assigned to most anesthesia services. This value is based on the comparative difficulty of the anesthesia administered, and includes the preoperative, preanesthetic and postoperative care and evaluation, and is part of the formula used to determine reimbursement for anesthesia services. The Company applies the Centers for Medicare & Medicaid Services (CMS) anesthesia base units to anesthesia services with an assigned value.

Anesthesia qualifying circumstances codes reflect the variable circumstances or conditions (e.g., complications due to an emergency condition, a patient's advanced age) that require additional skill and/or intervention by the anesthesia provider that is beyond those usually required.

Anesthesia modifiers are two digit alphanumeric codes that are used to indicate additional information about anesthesia procedures and services for the processing of anesthesia claims. For example, an anesthesia modifier may indicate the professional provider who performed the anesthesia service or the physical status of the individual (P1-P6). The physical status modifiers identify levels of complexity of the anesthesia services and are reported in conjunction with anesthesia procedure codes when appropriate.

The conversion factor is the dollar value multiplied by the total units (time unit + base unit) to equal the reimbursement for most anesthesia services.
References

Centers for Medicare & Medicaid Services (CMS). Anesthesiologists Center. Anesthesia Base Units by CPT Code [CMS Web site]. Available at:http://www.cms.gov/Center/Provider-Type/Anesthesiologists-Center.html. Accessed May 17, 2018.


Centers for Medicare & Medicaid Services (CMS). Medicare Claims Processing Manual. Chapter 12: Physicians/Nonphysician practitioners. 50 - Payment for anesthesiology services. [CMS Web site]. Available at: http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf. Accessed July 24, 2019

Centers for Medicare & Medicaid Services (CMS). Medicare Learning Network: Advanced Practice Registered Nurses, Anesthesiologist Assistants, and Physician Assistants.[CMS Web site]. Available at:
http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/APNPA.html. Accessed May 17, 2018.

Centers for Medicare & Medicaid Services (CMS). National Correct Coding Initiative Edits.01/2019. Available at: https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html?redirect=/nationalcorrectcodinited/. Accessed: July, 24, 2019

Optum360. Understanding Modifiers 2018. West Salt Lake City, UT: Optum360; 2017.

American Society of Anesthesiologists (ASA). ASA Annual Meeting Abstracts. Billing for preoperative anesthesia consultations for cancelled surgeries. (ASA Annual Meeting Abstracts Web site.) 08/ 2008. Available at: http://www.asaabstracts.com/strands/asaabstracts/abstract.htm;jsessionid=2A371048FC3609B07E0A6462F740D9BC?year=2004&index=15&absnum=1404. Accessed: July, 24, 2019

State of New Jersey. Subchapter 4a. Surgery, Special Procedures, and Anesthesia Services Performed In An Office Setting. [New Jersey State Administrative Code]. https://www.njconsumeraffairs.gov/bme/Documents/Adoption-Surgery-Special-Procedures-and-Anesthesia-Services-Performed-In-An-Office-Setting.pdf. Accessed: 11/08/2019

State of Pennsylvania Department of Health. Hospital Regulations Anesthesia and Respiratory Services, Title 28 § 123.1. [State of Pennsylvania Department of Health]. Available at: https://www.health.pa.gov/topics/Documents/Facilities%20and%20Licensing/028_0123.pdf. Accessed 11/08/2019



Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

FOR A LIST OF THE AMERICAN SOCIETY OF ANESTHESIOLOGISTS (ASA) ANESTHESIA PROCEDURE CODES 00100-01999), REFER TO ATTACHMENT A.

QUALIFYING CIRCUMSTANCES CODES

99100, 99116, 99135, 99140

MODERATE SEDATION

99151, 99152, 99153, 99155, 99156, 99157



Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD-10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD-10 Diagnosis Code Number(s)

N/A


HCPCS Level II Code Number(s)

DENTAL/ORAL SURGERY SEDATION AND ANESTHESIA CODES

D9222Deep sedation/general anesthesia - first 15 minutes; Anesthesia time begins when the doctor administering the anesthetic agent initiates the appropriate anesthesia and non-invasive monitoring protocol and remains in continuous attendance of the patient. Anesthesia services are considered completed when the patient may be safely left under the observation of trained personnel and the doctor may safely leave the room to attend to other patients or duties.
D9223Deep sedation/general anesthesia - each subsequent 15 minute increment
D9239Intravenous moderate (conscious) sedation/analgesia- first 15 minutes; Anesthesia time begins when the doctor administering the anesthetic agent initiates the appropriate anesthesia and non-invasive monitoring protocol and remains in continuous attendance of the patient. Anesthesia services are considered completed when the patient may be safely left under the observation of trained personnel and the doctor may safely leave the room to attend to other patients or duties.
D9243Intravenous moderate (conscious) sedation/analgesia - each subsequent 15 minute increment
MODERATE SEDATION
G0500Moderate sedation services provided by the same physician or other qualified health care professional performing a gastrointestinal endoscopic service that sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intra-service time; patient age 5 years or older (additional time may be reported with 99153, as appropriate)



Revenue Code Number(s)

N/A


Misc Code

MODIFIERS:

A MODIFIER FROM THE FOLLOWING LIST IS REQUIRED TO BE REPORTED WHEN REPORTING ANY ANESTHESIA PROCEDURE CODE LISTED IN ATTACHMENT A:

PERFORMANCE VERIFICATION MODIFIERS

AA Anesthesia services performed personally by anesthesiologist
AD Medical supervision by a physician: more than four concurrent anesthesia procedures
GC  This service has been performed in part by a resident under the direction of a teaching physician
QKMedical direction of two, three or four concurrent anesthesia procedures involving qualified individuals
QXCRNA service: with medical direction by a physician
QYMedical direction of one certified registered nurse anesthetist (CRNA) by an anesthesiologist
QZCRNA service: without medical direction by a physician
MONITORED ANESTHESIA (MAC) MODIFIERS

QSMonitored anesthesiology care service
G8Monitored anesthesia care (MAC) for deep complex, complicated, or markedly invasive surgical procedure
G9  Monitored anesthesia care for patient who has history of severe cardiopulmonary condition


PHYSICAL STATUS MODIFIERS

P1A normal healthy patient
P2A patient with mild systemic disease
P3A patient with severe systemic disease
P4A patient with severe systemic disease that is a constant threat to life
P5A moribund patient who is not expected to survive without the operation
P6A declared brain-dead patient whose organs are being removed for donor purposes

NOT ELIGIBLE FOR SEPARATE REIMBURSEMENT

47 Anesthesia by surgeon



Coding and Billing Requirements


Cross References

Attachment A: Reporting and Documentation Requirements for Anesthesia Services
Description: ASA Anesthesia Procedure Codes



Policy History

REVISIONS FROM 00.01.14r
4/20/2020This version of the policy will become effective 04/21/2020. The following criteria have been added to the policy:
  • Performance and oversight of Medical Direction
  • Requirements and criteria for a non-anesthesia provider performing anesthesia AND administering anesthesia
  • Clarification on reporting anesthesia for providers (time and modifier reporting)
  • Expanded and clarified language in regards to reporting of multiple anesthesia procedures
  • Billing requirements for surgeons performing anesthesia and surgical procedures
The Company's coverage of Moderate Sedations has changed to reflect American Medical Association and CMS guidelines.

The Company's reimbursement position for preoperative consultations and E & M services has changed from eligible for reimbursement to not eligible for separate reimbursement.

The Company's reimbursement position has changed from considering combined time of each anesthesia service performed to total time anesthesia administration

Criteria and reporting instructions added for preoperative services and discontinued anesthesia services added from archived policies:
01.00.08c Preoperative Consultations Performed by Providers in Anesthesia Specialties
01.00.02b Anesthesia Services for a Cancelled or Discontinued Procedure

REVISIONS FROM 00.01.14q:
01/01/2019As of 01/01/2019, revised policy number 01.01.14q is being issued to make a change to reimbursement methodology for anesthesia services. Reimbursement for the physical status modifiers (P1-P6) will be discontinued. Going forward, these modifiers are to be reported for informational purposes only.

Effective 10/05/2017 this policy has been updated to the new policy template format.
Version Effective Date: 04/20/2020
Version Issued Date: 04/20/2020
Version Reissued Date: N/A



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