ANESTHESIA CODING GUIDELINES
The use of the CPT anesthesia codes is not a requirement. We will accept either the CPT surgical/medicine codes (10020-69999 and 90000 series) or the CPT anesthesia codes (00100-01999) with the appropriate anesthesia modifier appended. However, please keep in mind that some out-of-state Blue Cross and Blue Shield Plans will only accept the CPT anesthesia codes (00100-01999).
APPLICATION OF POLICY AND CLAIMS FILING GUIDELINES
This policy is applicable to independent practitioners (i.e., anesthesiologists and certified registered nurse anesthetists) as well as hospital-based practitioners who file professional anesthesia services.
Claims Filing Guidelines for State & School Employees Health Insurance Plan
Independent and hospital-based anesthesiologists and certified registered nurse anesthetists (CRNAs) must file both inpatient and outpatient professional anesthesia services on a HCFA-1500 form.
Claims Filing Guidelines for All Other Lines of Business
Independent practitioners (anesthesiologists and CRNAs) must file professional anesthesia services on a CMS -1500 form.
Hospital-based practitioners (anesthesiologists and CRNAs) must file professional anesthesia services as hospital ancillary services on the UB-04 form. However, if the hospital is participating in Blue Cross & Blue Shield of Mississippi (BCBSMS) APG Reimbursement Program, outpatient professional anesthesia services must be filed on a CMS-1500 claim form.
When the professional anesthesia services are filed on a CMS-1500 claim form and a CRNA is involved in the administration of the anesthesia, the following rules apply:
If electronic claims are filed incorrectly, they will be rejected and you will receive an error report. If hardcopy claims are filed incorrectly, they will be returned. Errors must be corrected on all rejected and returned claims, and the claims must be filed again.
CODING GUIDELINES FOR GENERAL ANESTHESIA
When filing general anesthesia services, Blue Cross & Blue Shield of MS (BCBSMS) will accept the CPT surgical/medicine procedure codes or the CPT anesthesia codes. The appropriate HCPCS Level II anesthesia modifier and anesthesia time are required when filing both code sets.
BCBSMS requires the use of the following HCPCS Level II modifiers when filing general anesthesia claims with service dates on or after January 1, 2002.
Modifiers Used By Anesthesiologists
Modifier AA Anesthesia services performed personally by anesthesiologist
Modifier AD Medical supervision by a physician (anesthesiologist); more than four concurrent anesthesia procedures
Modifier QK Medical direction (supervision) of two, three or four concurrent anesthesia procedures
Modifier QY Anesthesiologist medically directs one CRNA
Modifiers Used By CRNAs
Modifier QX CRNA service with medical direction (supervision) by a physician
Modifier QZ CRNA service without medical direction (supervision) by a physician
Note: Modifiers AB and AC were deleted from the HCPCS Manual on January 1, 2000. These modifiers will not be accepted by BCBSMS for claims with a service date of January 1, 2002 or after.
Filing General Anesthesia Services When Multiple Surgical Procedures Are Performed
When multiple surgical procedures are performed during an operative setting, only the procedure with the highest anesthesia base units should be reported. It should be noted that the primary surgical procedure is not always the procedure with the highest anesthesia base units. Check the most recent issue of the American Society of Anesthesiologists Relative Value Guide for the procedure with the highest relative value units.
Global Anesthesia Services
The following components are considered an integral part of the global service for general anesthesia and should not be reported separately.
Physical Status Modifiers, Qualifying Circumstances, and Specialized Monitoring
The following services are not considered a part of the global service for general anesthesia and can be reported as a separate line item on the claim form. In order to receive the correct reimbursement for these services, they must be submitted on the same claim form as the global anesthesia services.
Physical Status Modifiers are appended to the global anesthesia service code following the HCPCS Level II modifier (e.g., 25270-AA-P3).
Qualifying Circumstances: Anesthesia time and modifiers are not required with these procedures.
Specialized Monitoring and Other Miscellaneous Procedures: Anesthesia time and modifiers are not required with these procedures.
Guidance Procedures: Anesthesia time and modifiers are not required with these procedures.
76986 Ultrasonic guidance, intraoperative
When Insertion of an Arterial Line or Catheter Is the Only Service Rendered
When the insertion of an arterial line or catheter is the only service rendered, submit the charge using the appropriate code. Anesthesia modifiers and time are not required.
Anesthesia time should be reported in minutes in Field 24G on the HCFA-1500 form. BCBSMS allows one unit of time for each 15-minute increment of anesthesia time. There is an exception to this policy. See the section entitled "Epidural Anesthesia Administered by an Anesthesiologist and/or CRNA".
Calculating Anesthesia Allowable Charges
Below is the formula used to calculate the allowable charge for general anesthesia.
Anesthesia Allowable Charge = ( Anesthesia Base Units + Anesthesia Time Units + Physical Status Modifier + Qualifying Circumstances + Specialized Monitoring) x Anesthesia Conversion Factor
INSERTION OF AN EPIDURAL CATHETER FOLLOWING GENERAL ANESTHESIA FOR POST-OPERATIVE PAIN MANAGEMENT
Use CPT code 62318 or 62319 to report the insertion of an epidural catheter for post-operative pain management. Modifier -59 is required when filing this service. Anesthesia modifiers and time are not required when reporting the insertion of an epidural catheter.
Use anesthesia code 01996 to report daily management of an epidural catheter. The anesthesia modifiers and anesthesia time are not required with this code. No benefits are allowed for this service on the day that the catheter is placed. Documentation of medical necessity is required for visits in excess of three (3) days.
PATIENT-CONTROLLED ANALGESIA (PCA) PUMP
The set-up, daily management, and supervision of a PCA pump are inclusive in the global anesthesia service when performed by an anesthesiologist or CRNA. If you bill separately for this service, please use code 01999. Anesthesia modifiers and time are not required when filing this service.
REGIONAL ANESTHESIA (i.e., BIER BLOCK)
Applicable to claims with service dates on or after January 1, 2007
A Bier Block is an intravenous (IV) regional block that involves the use of a tourniquet to restrict the effects of the anesthesia to a region of the body (i.e., arm or leg). When regional IV administration of a local anesthetic agent or other medication in the upper or lower extremity is used as the anesthetic for a surgical procedure, report the appropriate ASA anesthesia code. The appropriate anesthesia modifier and anesthesia time are required when reporting this service.
When a Bier Block is administered for pain management, report unlisted code 64999. For intra-arterial or intravenous therapy for pain management, report code 90773 or 90774.
Applicable to claims with service dates prior to January 1, 2007
Regional anesthesia involves the use of a tourniquet to restrict the anesthesia to a region of the body, such as an arm or leg. Use ASA anesthesia code 01995 (Regional IV administration of local anesthetic agent upper or lower extremity) to report regional anesthesia services. Anesthesia modifiers and time are not required when reporting ASA code 01995.
MONITORED ANESTHESIA CARE (MAC)
According to the American Society of Anesthesiologists Relative Value Guide, "Monitored anesthesia care is a specific anesthesia service for a diagnostic or therapeutic procedure. Indications for monitored anesthesia care include the nature of the procedure, the patient's clinical condition and/or the potential need to convert to a general or regional anesthetic." It further states that, "An essential component of MAC is the anesthesia assessment and management of a patient's actual or anticipated physiological derangements or medical problems that may occur during a diagnostic or therapeutic procedure."
Monitored anesthesia care is covered only if the services are deemed medically necessary. The medical necessity for MAC or general anethesia must be documented in the patient's anesthesia records. The information documented in the patient's anesthesia record must be supported by the patient's medical history obtained from the other medical providers and institutions.
The use of moderate sedation, given by the physician performing the procedure, has proven to be safe and to promote patient comfort. Moderate sedation should be used in those procedures when it is deemed safe. We have not found anything in our research which indicates that MAC is safer than moderate conscious sedation in those procedures where moderate sedation is deemed appropriate. However, for patients who have sedation-related risks, MAC is appropriate and will be covered by all applicable contracts.
Some providers are routinely using monitored anesthesia care (MAC), which requires the involvement of an anesthesiologist or CRNA. This adds unnecessary cost to our members. It is our responsibility to help ensure that our members receive quality and cost-effective care.
We hope that our policy regarding MAC is not misinterpreted and incorrectly communicated to our members.
MODERATE (CONSCIOUS) SEDATION
Moderate (conscious) sedation is a drug induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are required to maintain a patient airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained during this time.
When providing moderate (conscious) sedation, certain services are included and not reported separately. The service services include assessment of the patient (not included in intraservice time), establishment of IV access and fluids to maintain patency, when performed; administration of agent(s), maintenance of sedation, monitoring of oxygen saturation, heart rate and blood pressure; and recovery (not included on intraservice time).
Moderate sedation does not include minimal sedation (anxiolysis), deep sedation or monitored anesthesia care (00100-01999).
Moderate Sedation Provided by the Physician Performing the Procedure (99143-99145)
CPT codes 99143-99145 are used to report moderate (conscious) sedation provided by a physician also performing the service for which moderate sedation is being provided.
NOTE: Appendix G of the CPT manual lists a summary of CPT codes that include moderate sedation as an inherent part of providing the procedure. Since these services include moderate sedation, it is not appropriate for the same physician to report both the service and the sedation codes 99143-99145.
Moderate Sedation Provided by a Practitioner Other Than the Physician Performing the Procedure (99148-99150)
When a second physician other than the healthcare professional performing the diagnostic or therapeutic services provides moderate sedation in the facility setting (e.g., hospital, outpatient hospital/ambulatory surgery center, skilled nursing facility) for the procedures listed in Appendix G of the CPT manual, the second physician should report the appropriate code from the 99148-99150 code range.
However, for the circumstance in which these services are performed by the second physician in the non-facility setting (e.g., physician office, freestanding imaging center), codes 99148-99150 are not reported with the codes listed in Appendix G because moderate sedation is included in these codes.
For procedures identified in Appendix G of the CPT manual, general anesthesia and monitored anesthesia care (MAC) are covered only if the services are deemed medically necessary. If any of the conditions or situations, identified in the American Society of Anesthesiologists Relative Value Guide, create a clinical environment in which it becomes medically necessary to utilize general or MAC anesthesia in lieu of moderate conscious sedation, then these conditions and/or situations must be documented in the patient's anesthesia records.
NEURAXIAL LABOR ANALGESIA/ANESTHESIA ADMINISTERED BY AN ANESTHESIOLOGIST AND/OR CRNA FOR OBSTETRICAL PROCEDURES
When neuraxial labor analgesia/anesthesia is administered by an anesthesiologist or CRNA, report anesthesia code 01967 with the appropriate anesthesia modifier appended. Anesthesia time is also required when filing code 01967. The time units for this code are calculated in 30-minute increments rather than 15-minute increments.
If the neuraxial labor analgesia results in a cesarean delivery or cesarean hysterectomy, report codes 01968 or 01969, whichever is appropriate. Anesthesia modifiers and anesthesia time are required when filing codes 01968 and 01969.
Use code 01996 to report daily hospital management of epidural or subarachnoid drug administration. Anesthesia modifiers and time are not required when filing code 01996.
Occasionally, the neuraxial labor analgesia/anesthesia is performed by one practitioner and the administration of anesthesia during the cesarean delivery or cesarean hysterectomy is performed by a different practitioner. If this occurs, the appropriate code should be filed with the appropriate anesthesia modifier. Several examples are included below to assist you in filing claims in this situation.
Example #1: The neuraxial labor analgesia/anesthesia (01967) is personally performed by the anesthesiologist, and the anesthesia for the cesarean delivery (01968) is performed by a CRNA while the anesthesiologist supervises (medically directs one CRNA). The CRNA is not employed by the same practice as the anesthesiologist.
Note: In the above example, a separate claim would be filed by the CRNA. Since the CRNA is not involved in the administration of the neuraxial labor analgesia, the CRNA would report anesthesia administered for the cesarean delivery only. We have revised our policy to allow the CRNA in the above example to file "add-on" code 01968-QX as a stand-alone code on a separate claim without code 01967. CRNAs should no longer use code 01961-QX to file the administration of anesthesia during the cesarean delivery in the above case scenario. This change in policy also applies to "add-on" code 01969. It can also be report as a stand-alone code on a separate claim when applicable.
Example #2: The neuraxial labor analgesia/anesthesia (01967) is personally performed by the anesthesiologist and the anesthesia for the cesarean delivery (01968) is performed by a CRNA while the anesthesiologist supervises (medically directs two CRNAs). The CRNA is employed by the same practice as the anesthesiologist.
Example #3: The neuraxial labor analgesia/anesthesia (01967) is performed by the CRNA and the anesthesia for the cesarean delivery (01968) is performed by the supervising anesthesiologist (medically directs one CRNA). The CRNA is employed by the same practice as the anesthesiologist.
General Note: On the line item for the neuraxial analgesia/anesthesia (01967), include only the anesthesia time for the labor. On the line item for the cesarean delivery (01968), include only the anesthesia time for the delivery.
EPIDURAL ANESTHESIA ADMINISTERED BY AN ANESTHESIOLOGIST AND/OR CRNA FOR NON-OBSTETRICAL PROCEDURES
Use the appropriate CPT surgical/medicine procedure code or CPT anesthesia code to report epidural anesthesia for non-obstetrical procedures. Anesthesia modifiers and anesthesia time are required.
PAIN MANAGEMENT (NON-SURGICAL)
Use the appropriate CPT code (e.g., 20550, 20605, 20610, 64400-64530, etc.) to report services for the management of pain not directly related to the performance of a surgical procedure. Anesthesia modifiers and anesthesia time are not required when reporting pain management services.
GENERAL ANESTHESIA FOR RADIOLOGICAL PROCEDURES (MRI & CAT SCAN) OR RADIATION THERAPY
To report general anesthesia services for radiological procedures or radiation therapy, use the appropriate CPT anesthesia code from range 01916-01933. Anesthesia modifiers and time are required when reporting these services.
Electronic filing is always the preferred method of filing claims and now all claim types can be filed electronically. If you encounter problems filing electronically, or want to get started, please contact one of our EDI service representatives at 601-664-4357.
POLICY EXCEPTIONSThis policy is applicable to all lines of business, including the State of MS and the Federal Employee Program (FEP).
BCBSMS no longer places restrictions on the use of the CPT anesthesia codes (00100-01999). All anesthesia codes are now accepted.
POLICY GUIDELINESThe coding guidelines outlined in Coding Policy should not be used in lieu of the Member's specific benefits plan language.
POLICY HISTORY1/2002: Policy developed
3/2003: Policy revised
9/15/2003: Time limit on code 01968 increased from one hour to two hours
11/18/2003: Time limit on code 01967 increased from five hours to six hours
5/20/2004: Codes 36488, 36489, 36490, 36491 were deleted from policy. Codes 36555 and 36556 were added.
3/2/2005: Title of policy changed from "Anesthesia - 2003" to "Anesthesia." The time limit maximums have been removed from all codes. Policy revised to indicate that "add-on" codes 01968 and 01969 can now be submitted as stand-alone codes on a separate claim without code 01967, when applicable. The following statement has been removed from claims Example #1 above: "The CRNA should report code 01961-QX. In this example, it would be inappropriate for the CRNA to report 'add-on' code 01968. Code 01968 should only be billed in conjunction with code 01967. This policy also applies to "add-on" code 01969." See new policy under claims Example #1 above.
The following statement was removed from Policy Exceptions: "ASA anesthesia codes are accepted only in the rare instances indicated in the policy, with the exception of Medicare crossover claims. All ASA codes are accepted on Medicare crossover claims." See revision under Policy Exceptions above.
Post operative injections given for pain management will now receive separate reimbursement. This service is no longer considered an integral part of the administration of general anesthesia. This change in policy is effective on claims processed after August 27, 2004.
Codes 36488, 36489, 36490, 36491 have been deleted from the Specialized Monitoring Procedures table.
5/17/06: The policy was updated to add the rare circumstances for which additional units are allowed for hypothermia anesthesia; added guidelines for moderate (conscious) sedation; updated the units for the injection codes for nonneurolytic substances.
3/16/07: Policy updated to add guidelines for anesthesia billed for codes listed in Appendix G that include moderate conscious sedation.
8/3/2007: Policy updated to add guidelines for claims submitted after January 1, 2007 for regional anesthesia.
8/24/2007: Policy updated to address appropriate reporting of services due to changes made to CMS-1500 forms.
12/12/2007: Policy updated per the 2008 CPT/HCPCS revisions. Code 01905 deleted.
07/03/2008: Policy updated to add additional guidelines regarding Monitored Anesthesia Care (MAC)
11/26/2008: Intubation, endotracheal, emergency procedure (31500) listed as an inclusive component when performed as part of the global anesthesia service.
06/25/2009: Codes 93312, 93314, 93315 and 93317 were added to the Specialized Monitoring Procedure table