Anesthesia Reimbursement & Services Reporting - Medicare Advantage

Policy No: 102
Date of Origin: 11/01/2013
Section: Anesthesia
Last Reviewed: 03/01/2023
Last Revised: 03/01/2023
Approved: 03/09/2023
Effective: 04/01/2023
Policy applies to: Medicare Advantage

This policy applies only to physicians an other qualified health care professionals.

Anesthesia
The administration of a drug or anesthetic agent by an anesthesiologist or Certified Registered Nurse Anesthetist (CRNA) for medical or surgical purposes to obtain muscular relaxation, induce partial or total loss of sensation and/or consciousness.

Base Units
Our health plan uses Centers for Medicare & Medicaid Services (CMS) base units.

Modifiers P1 through P6
Modifiers used with anesthesia codes that reflect the physical status of the patient receiving anesthesia.

• Modifier P1 (Physical Status Units 0) - Current Procedural Terminology (CPT®) anesthesia physical status modifier P1 represents a normal healthy patient.
• Modifier P2 (Physical Status Units 0) - CPT anesthesia physical status modifier P2 represents a patient with mild systemic disease.
• Modifier P3 (Physical Status Units 0) - CPT anesthesia physical status modifier P3 represents a patient with severe systemic disease.
• Modifier P4 (Physical Status Units 0) - CPT anesthesia physical status modifier P4 represents a patient with severe systemic disease that is a constant threat to life.
• Modifier P5 (Physical Status Units 0) - CPT anesthesia physical status modifier P5 represents a moribund patient who is not expected to survive without the operation.

• Modifier P6 (Physical Status Units 0) - CPT anesthesia physical status modifier P6 represents a declared brain-dead patient whose organs are being removed for donor purposes.

Modifier 59
Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-E/M services performed on the same day. Modifier 59 is used to identify procedures/services, other than E/M services, that are not normally reported together, but are appropriate under the circumstances. Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. However, when another already established modifier is appropriate it should be used rather than modifier 59. Only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. Note: Modifier 59 should not be appended to an E/M service.

Modifier XE
Separate encounter, a service that is distinct because it occurred during a separate encounter.

Modifier XU
Unusual nonoverlapping service, the use of a service that is distinct because it does not overlap usual components of the main service.

Time Units
The time starting when the anesthesiologist or CRNA begins to prepare the patient for anesthesia care in the operating room or equivalent area, and ending when the anesthesiologist or CRNA is no longer in personal attendance, that is, when the patient is safely placed under post-anesthesia supervision.

This time is billed in minutes. The minutes are then divided into increments used in calculating anesthesia reimbursement. Our health plan uses 15-minute increments; 4 units per hour. Increments of less than 15 minutes will not be counted as 1 unit.

Note: This policy has been revised. The revised policy will be effective 11/1/2024. To view the revised policy, click here

The anesthesia codes (00100 – 01999) listed in the current edition of Current Procedural Terminology (CPT) are the only anesthesia codes recognized for reimbursement by our health plan.

Our health plan follows CMS methodology in reimbursing anesthesia services.

Anesthesia services should be reported using the appropriate codes from the anesthesia section of the CPT manual. Physical status modifiers P1 – P6 may be appended to the anesthesia code when applicable.

Anesthesia time begins when the anesthesiologist begins to prepare the patient for anesthesia care in the operating room or in an equivalent area and ends when the anesthesiologist is no longer in personal attendance, i.e., when the patient is safely placed under post-anesthesia supervision. The time reported should be coded in minutes in the units field of the billing format.

Services performed in conjunction with a surgical anesthetic are considered an integral part of that anesthesia service and therefore not eligible for separate reimbursement. These services include but are not limited to:

• Arterial blood gas analysis/monitoring
• Blood pressure monitoring
• Carbon dioxide monitoring
• Moderate conscious sedation
• EEG/EKG monitoring
• Evaluation & management services
• Field avoidance
• Heparin analysis
• Intraoperative monitoring
• Esophageal doppler hemodynamic management
• Intubation
• Local anesthesia (for regional or field block)
• Nerve block (except as noted in this policy)
• Oximetry/pulse oximetry
• Patient controlled analgesia
• Patient position
• Regional IV of local anesthetic
• Supplies and equipment

• Ventilator set-up and/or management

Although some of these services may never be reported on the same date of service as an anesthesia service, many of these services could be provided at a separate patient encounter unrelated to the anesthesia service on the same date of service. Modifiers 59 or XE should be appended under these circumstances.

Postoperative pain management services are generally provided by the surgeon who is reimbursed under a global payment policy related to the procedure. These services shall not be reported by the anesthesia practitioner unless separate, medically necessary services are required that cannot be rendered, and have been requested, by the surgeon.

Epidural for Postoperative Pain
The pre-operative placement of an epidural catheter for postoperative pain relief is eligible for separate reimbursement to a provider other than the attending surgeon when:

1. the epidural catheter is not used as the primary surgical anesthetic, and

2. the appropriate epidural catheter code is submitted as a distinct procedural service

The reimbursement made for the placement of an epidural catheter includes payment for all related professional service(s) on that same date of service, including but not limited to: writing orders for medication, services related to the maintenance of the epidural catheter, services related to care of patient's pain and any injections of an anesthetic substance.

Daily management of an epidural or subarachnoid drug administration (CPT code 01996) is eligible for reimbursement once per date of service for up to three postoperative days beginning the day after the surgery. Charges for four or more days of this service may be reviewed for possible reimbursement. Code 01996 is not eligible for reimbursement on the day the epidural catheter was placed.

Nerve Blocks
An epidural or peripheral nerve block injection for postoperative pain management in patients receiving general anesthesia, spinal (subarachnoid injection) anesthesia, or regional anesthesia by epidural injection may be administered preoperatively, intraoperatively, or postoperatively.

Nerve blocks administered by an anesthesiologist or CRNA as a component of the anesthesia are not eligible for separate reimbursement as they are considered a component of the anesthesia. Nerve blocks administered by an anesthesiologist or CRNA specifically for postoperative pain management are eligible for separate reimbursement. Modifiers 59, or XU should be appended to the nerve block code.

When eligible for separate reimbursement, the nerve block code should be billed consistent with other non-anesthesia CPT codes and not billed using ASA units (base + time).

Acupuncture
Acupuncture procedure codes when used as an anesthetic are not eligible for reimbursement.

Anesthesia by Surgeon
Moderate sedation is eligible for separate reimbursement to the surgeon if:

1. Medicare's National Correct Coding Initiative (NCCI) does not deny the moderate sedation code as included in the primary procedure.

2. Our health plan's Correct Code Editor (CCE) does not deny the moderate sedation code as included in the primary procedure.

Reimbursement for all other methods of delivering anesthesia will be denied, including but not limited to, nerve blocks, local, topical and regional anesthesia services, when provided by the same physician performing the medical or surgical service.

Stand-by Anesthesia
Stand-by anesthesia or trauma team stand-by anesthesia do not provide direct patient care and therefore are not eligible for separate reimbursement.

Centers for Medicare & Medicaid Services, Medicare Claims Processing Manual, Chapter 12, Section 50 “Payment for Anesthesiology Services.”

National Correct Coding Initiative Coding Policy Manual for Medicare Services (Coding Policy Manual). Chapter 2.

Current Procedural Terminology (CPT) 2022 Professional Edition. Anesthesia Guidelines.

AllMed – a company that provides utilization management and independent medical review services that support optimal member outcomes and appropriate utilization.

Global Days
Incidental Procedures
Correct Coding Guidelines
Modifiers 59, XE, XP, XS, XU; Distinct Procedural Service