Anesthesia Modifiers - P1 - P6 modifier

Anesthesia Modifiers Including Physical Status Modifiers:

All anesthesia services are reported by use of the anesthesia five-digit procedure code (00100-01999) plus the addition of a physical status modifier. The use of other optional modifiers may be appropriate.

Physical Status Modifiers

Physical Status modifiers are represented by the initial letter 'P' followed by a single digit from 1 to 6

defined below:

P1 - A normal healthy patient.

P2 - A patient with mild systemic disease.

P3 - A patient with severe systemic disease.

P4 - A patient with severe systemic disease that is a constant threat to life.

P5 - A moribund patient who is not expected to survive without the operation.

P6 - A declared brain-dead patient whose organs are being removed for donor purposes.

The above six levels are consistent with the American Society of Anesthesiologists (ASA) ranking of patient physical status. Physical status is included in CPT to distinguish between various levels of

complexity of the anesthesia service provided.

Example: 00100-P1

Other Modifiers (Optional)

Under certain circumstances, medical services and procedures may need to be further modified. Other

modifiers commonly used in Anesthesia are included below. A complete list of modifiers and their

respective codes are listed in Appendix A.

-22 Unusual Procedural Services: When the service(s) provided is greater than that usually

required for the listed procedure, it may be identified by adding modifier '-22' to the usual procedure

number or by use of the separate five digit modifier code 09922. A report may also be appropriate.

-23 Unusual Anesthesia: Occasionally, a procedure which usually requires either no anesthesia or

local anesthesia, because of unusual circumstances must be done under general anesthesia. This

circumstance may be reported by adding the modifier '-23' to the procedure code of the basic service

or by use of the separate five digit modifier code 09923. Note: Modifier '-47', Anesthesia by

Surgeon, (see modifier section) would not be used as a modifier for the anesthesia procedures 00100-

01999.

-32 Mandated Services: Services related to mandated consultation and/or related services (eg,

PRO, 3rd party payer) may be identified by adding the modifier '-32' to the basic procedure, or the

service may be reported by use of the five digit modifier 09932.

Anesthesia billing services - BCBS

Anesthesia Payment & Billing Information - BCBS

Time and Points Eligible Anesthesia Procedures Defined

HMO Blue Texas and Blue Cross and Blue Shield of Texas have determined that certain anesthesia procedures will be reimbursed on time and points methodology.

Procedures that are not included on the Anesthesia Time & Points Eligible List will not be reimbursed using time and points methodology. If a procedure is not on this list, and it is submitted using anesthesia indicators for Time & Points such as:

using an anesthesia modifier, or

using time on the claim, or

 if submitted on a non-HIPAA claim format, (Type of Service = 7) then the provider may receive a denial message for that procedure noting that the service is not eligible for time and points payment methodology.

Anesthesia Services

Services involving administration of anesthesia should be reported by the use of the Current Procedural Terminology (CPT) anesthesia five-digit procedure codes, American Society of Anesthesiologists (ASA) or CPT 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 (CPT) 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.

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

BCBS - Anesthesia Modifier reimbursement

Anesthesia Payment & Billing Information - BCBS

Anesthesia Modifier Reimbursement :

Effective for dates of service on or after May 19, 2004, the HMO Blue Texas and Blue Cross and Blue Shield of Texas maximum allowable fees for services billed as MD supervision of a CRNA are as follows:

QY MD supervision of a CRNA $325.52

QK MD supervision of a CRNA $310.01

AD MD supervision of a CRNA $162.76

OB Time and Points Maximum Allowable Points : 

The following are the current HMO Blue Texas and Blue Cross and Blue Shield of Texas total maximum allowable points for Vaginal or Cesarean deliveries:

Obstetrical Vaginal delivery: 23 total maximum allowable points

Obstetrical Cesarean delivery: 32 total maximum allowable points

If general anesthesia is used in the performance of any obstetrical Vaginal or Cesarean delivery, the maximum allowable points are applicable. In the event that total actual points are less than the total maximum allowable points, you will be reimbursed based on total actual points.

Reimbursement of OB Anesthesia Add-On Codes 01968 and 01969 :

When a primary OB delivery anesthesia procedure (01967) is billed with either 01968 and/or 01969, HMO Blue Texas and Blue Cross and Blue Shield of Texas allows a combined maximum of 32 points.

Aneshthesia Time-Based Units

During the first 4 hours of service, 15 minutes equals 1 unit. If services are provided for longer than 4 hours in one occurrence, each 10-minute period after the initial 4 hours equals 1 unit. A period less than a unit should be rounded up to the next unit.

Example A: 5 hours or 300 minutes equals 22 units – 16 units for the first 4 hours (1 unit per each 15 minutes) and 6 units for the last hour

(1 unit per each 10 minutes).

Example B: 128 minutes is billed as 9 units (8 units for the first 120 minutes and 1 additional unit for the remaining 8 minutes).

Completing the Claim Form

The following instructions are specific to anesthesia services and must be used in conjunction with the complete CMS-1500 Claim Form Instructions provided on First Health Services’ website (select “Billing Information” from the “Providers” menu).

· Field 19: When billing a time-based code, enter the total minutes of reportable anesthesia time in Field 19.

· Field 24D: On the bottom, white half of the claim line, enter one CPT code and one physical status modifier (P1-P6). List additional modifiers when appropriate.

· Field 24G:

o When using a time-based code, enter the number of reportable anesthesia time units; do not add base units or modifier units to the time units.

o When using an occurrence-based code, enter a “1” for each occurrence. The following codes are paid per occurrence: 01953, 01967, 01968, 01969, 01996, 99100, 99116, 99135 and 99140.

Anethesia billing - Introduction

Anesthesia care conventionally includes all services associated with the administration of analgesia/anesthesia, provided by an anesthesiologist and/or certified registered nurse anesthetist (CRNA)1 to a patient undergoing a surgical or other invasive procedure so that intervention can be undertaken. This may involve local, regional, epidural, general anesthesia or monitored anesthesia care (MAC), and usually involves administration of anxiolytics or amnesia-inducing medications. 

Additionally, anesthesia care includes preoperatively evaluating the patient with a sufficient history and physical examination so that the risk of adverse reactions can be minimized, planning alternative approaches to accomplishing anesthesia and answering all questions regarding the anesthesia procedure asked by the patient.

The anesthesiologist assumes responsibility for the post anesthesia recovery period which is included in the anesthesia care package. It encompasses all care until the patient is released to the surgeon or another physician; this point of release generally occurs at the time of release from the post anesthesia recovery area.

Anesthesia Billing Guideline CPT 99200, 99000,99070

Time Reporting:

Time for anesthesia procedures may be reported as is customary in the local area. Anesthesia time begins when the anesthesiologist begins to prepare the patient for the induction of anesthesia in the operating room or in an equivalent area and ends when the anesthesiologist is no longer in personal attendance, that is, when the patient may be safely placed under postoperative supervision.

Physicians Services:

Physician's services rendered in the office, home, or hospital, consultation and other medical services are listed in the "Codes" section entitled Evaluation and Management Services (99200 series). "Special Services and Reporting" (99000 series) are presented in the Medicine section.

Materials Supplied by Physician:

Supplies and materials provided by the physician (eg, sterile trays, drugs) over and above those usually included with the office visit or other services rendered may be listed separately. List drugs, tray supplies, and materials provided. Identify as 99070.

CPT CODE 99200, 99000,99070 Guide

CPT code and description

99000 - Handling and/or conveyance of specimen for transfer from the office to a laboratory -average fee amount-$0.00

99070 - Supplies and materials (except spectacles), provided by the physician or other qualified health care professional over and above those usually included with the office visit or other services rendered (list drugs, trays, supplies, or materials provided)

Handling fees, CPT codes 99000 and 99001

CPT codes 99000 and 99001 are designated as status B codes (bundled and never separately reimbursed) on the Physician Fee Schedule RBRVU file. Moda Health clinical edits will deny CPT 99000 or 99001 with explanation code WGO (Service/supply is considered incidental and no separate payment can be made. Payment is always bundled into a related service), whether 99000

or 99001 is billed with another code or as the sole service for that date. This edit is not eligible for a modifier bypass

Laboratory Handling

Laboratory handling and conveyance CPT codes 99000 and 99001 and HCPCS code H0048 are included in the overall management of a patient and are not separately reimbursed when submitted with another code, or when submitted as the only code on a claim for the same date of service.

Submitting CPT 99000 with Modifier 59

Blue Cross and Blue Shield of Texas (BCBSTX) regularly evaluates the coding practices of physicians and other providers who submit claims for services. This includes issues such as bundling and use of CPT modifiers.

BCBSTX recently studied the use of Modifier 59 (distinct procedural service) with the submission of CPT 99000 (handling and/or conveyance of specimen for transfer from the physician’s office to a laboratory).

Because CPT 99000 is purely an administrative service and not a procedure, BCBSTX considers use of Modifier 59 for this code to be inappropriate.

This inappropriate use of Modifier 59 results in an override of a claim system edit that considers CPT 99000 incidental to any other service performed on that date of service, including CPT 36415 for routine collection of venous blood, and results in overpayment. Please do not submit claims for CPT 99000 with Modifier 59.

Payment policy

10/16/06 “Specimen Handling and/or Conveyance or Implementation of Orders for Devices” to “Specimen Handling and/or Conveyance.” and clarified reimbursement policy for 99000.

Combined statements related to Therapeutic, prophylactic or diagnostic injection(Allergen Immunotherapy)and statements related Office Visit(s). Removed “Routine office visits provided in addition to preventive health office visits are considered mutually exclusive to the preventive health office visit.”

11/05/07 In the Pathologist section added code 85060 to the list of codes eligible for clinical interpretation. Changed the wording from “Pathology interpretation of all other codes in the 80002-87999 range is considered an integral service.” to “Pathology interpretation of all other codes in the 80002-87999 range is considered an integral to the laboratory test.” Changed the words “mutually exclusive” to “incidental” in the Cardiac Stress Test section. 

Removed code 93000 and 93040 because the incidental logic no longer applies to 99291 and 99292 in the Critical Care section. Code 93798 removed from the Electrocardiograms section. Removed code 82800, 82805, 82810, 93000, 93040 and 94640 because the incidental logic no longer applies to codes 99296, 99294, 99295, 99296 and 99298 in the Neonatal Intensive Care Services. 

Changed the word from “incidental” to “mutually exclusive” in the Transvaginal Ultrasound section. Removed the Maldistribution of Inspired Gas, hlamydia Testing by Direct or Amplified Probe Technique, Fluoroscopic Guidance and Voiding Pressure Studies section. Removed any deleted codes. Policy reviewed 10/26/07 by Senior Medical Director of Provider Partnerships, Medical and Reimbursement Policy.

6/7/2011 Further defined “When a lumbar laminectomy, facetectomy or foraminotomy is performed in conjunction with a lumbar spinal fusion procedure, the lumbar laminectomy, facetectomy or for aminotomy will be considered incidental to the lumbar spinal fusion.” Notification 3/15/2011 with an Effective date of 6/19/2011. (dpe)

Policy implementation information from 3/30/2006-05/05/2008 restored. Added information regarding After Hours Care and Specimen Handling. “After Hours Care - Reimbursement is not provided for CPT codes 99050 and 99051 for a facility credentialed and contracted as an urgent care center” and “CPT codes 99000 and 99001, the handling and/or conveyance of specimen, are eligible for payment to the provider’s office when the laboratory service is not performed in the provider’s office and the independent laboratory bills BCBSNC directly for the test. 

The independent laboratory/reference laboratory will not be reimbursed for 99000 and 99001.” Removed the following information from Topics of Frequent Interest Related to Blue Care, Blue Choice, Blue Options, and Classic Blue Products as not longer applicable : “Visual Acuity Screening - Visual acuity screening (99173) is considered incidental to routine office visits and preventive health visits.  separate reimbursement is not allowed for incidental services.” Notification given 6/7/2011 for effective date of 9/1/2011.

MATERIALS AND SUPPLIES – CPT CODE 99070

Anthem’s reimbursement for materials and supplies provided by the physician is included in the global reimbursement of the primary service being provided. Materials and supplies are not separately payable. Therefore, CPT code 99070 is not separately payable. If a provider bills with CPT code 99070 for a material or supply that is not usually part of the primary service, and CPT code 99070 is denied, the provider may call the Customer Service number listed on the member’s card or Provider Inquiry for a manual review of  the claim.

Anthem's reimbursement, if any, is reduced by any applicable deductibles, copayments and/or coinsurance as defined in the member’s contract for benefits and coverage. 99070 for Reporting Supplies, Materials, Supplements, Remedies, etc.

For HCFA1500 claims with dates of service 04/01/2015 and following, Moda Health will deny CPT code 99070 to provider write-off with an explanation code mapped to Claim Adjustment Reason Code 189 (Not otherwise classified or "unlisted" procedure code Page 3 of 10 (CPT/HCPCS) was billed when there is a specific procedure code for this procedure/service.). There is always a procedure code more specific than 99070 available to be used.

Correct coding guidelines require that the most specific, comprehensive code available be selected to report services or items billed. 

Moda Health accepts HCPCS codes for processing. Therefore, 99070 is never the most specific code available to use to report a supply, drug, tray, or material provided over and above those usually included in a service rendered.

Any HCPCS Level II code in the HCPCS book is more specific than 99070. The HCPCS book also includes a wide variety of more specific unlisted codes that should be used in  place of 99070 when the billing office cannot identify a listed HCPCS code to describe the supply or material being billed. The use of more specific HCPCS Level II procedure codes helps to ensure more accurate determination of benefits and processing of the claim.

It is important to note that not all HCPCS codes will be eligible for covered benefits under the member’s contract, and if covered, not all HCPCS codes will be eligible for separate reimbursement.

For reimbursement of covered medical and surgical supplies, an appropriate Level II HCPCS code must be submitted. The non-specific CPT code 99070 (supplies and materials, except spectacles, provided by the physician or other health care professional over and above those usually included with the office visit or other services rendered [list drugs, trays, supplies, or materials provided]) is not reimbursable in any setting

Supply Code L8680

Effective May 1, 2016 HCPCS code L8680 is no longer separately billable, with CPT code 63650, for Medicare because payment for electrode cost has been incorporated in CPT code 63650.

Anesthesia Billing Guideline CPT 99200, 99000,99070

Time Reporting:

Time for anesthesia procedures may be reported as is customary in the local area. Anesthesia time begins when the anesthesiologist begins to prepare the patient for the induction of anesthesia in the operating room or in an equivalent area and ends when the anesthesiologist is no longer in personal attendance, that is, when the patient may be safely placed under postoperative supervision.

Physicians Services:

Physician's services rendered in the office, home, or hospital, consultation and other medical services are listed in the "Codes" section entitled Evaluation and Management Services (99200 series). "Special Services and Reporting" (99000 series) are presented in the Medicine section.

Materials Supplied by Physician:

Supplies and materials provided by the physician (eg, sterile trays, drugs) over and above those usually included with the office visit or other services rendered may be listed separately. List drugs, tray supplies, and materials provided. Identify as 99070.

Anesthesia Billing form Guidelines

Prior Authorization

Anesthesia itself does not require prior authorization; however, prior authorization may be required for the related surgical procedure or service.

Time-Based Units

During the first 4 hours of service, 15 minutes equals 1 unit. If services are provided for longer than 4 hours in one occurrence, each 10-minute period after the initial 4 hours equals 1 unit. A

period less than a unit should be rounded up to the next unit.

Example A: 5 hours or 300 minutes equals 22 units – 16 units for the first 4 hours (1 unit per each 15 minutes) and 6 units for the last hour (1 unit per each 10 minutes).

Example B: 128 minutes is billed as 9 units (8 units for the first 120 minutes and 1 additional unit for the remaining 8 minutes).

Completing the Claim Form

· Field 19: When billing a time-based code,enter the total minutes of reportable anesthesia time in Field 19.

· Field 24D: On the bottom, white half of the claim line, enter one CPT code and one physical status modifier (P1-P6). List additional modifiers when appropriate

· Field 24G:

o When using a time-based code, enter the number of reportable anesthesia time units; do not add base units or modifier units to the time units.

o When using an occurrence-based code, enter a “1” for each occurrence. The following codes are paid per occurrence: 01953, 01967, 01968, 01969, 01996, 99100, 99116, 99135 and 99140.

CPT Code 99140

Medicaid carefully monitors for the appropriate use of code 99140 and modifiers P3, P4 and P5. Providers’ in-office records must verify medical necessity of this procedure.

Code 99140 should be used only for emergency conditions. This does not include a normal delivery or use of an epidural during delivery.

Anestesia billing CPT codes

CPT anesthesia modifier codes

Anesthesia billing

Aneshtesia claims denial - Time not in system

Anesthesia services: general, local, regional, epidural:

• We do not provide separate or additional reimbursement for the usual monitoring procedures that are traditionally part of and recorded on the anesthesia record because they are considered an integral part of anesthesia services and are included in the anesthesia base unit value. Unusual forms of monitoring (eg, intra-arterial, central venous and Swan-Ganz) are not included and may be billed separately.

• We do not provide separate or additional reimbursement for local anesthesia because it is considered part of the surgical procedure or other manipulation for which it is given.

• Moderate sedation services provided by the same physician performing the diagnostic or therapeutic service that the sedation supports should be reported with CPT codes 99143-99145.

Separate or additional reimbursement for moderate sedation services submitted with codes 99143-99145 is allowed according to CPT coding guidelines and should be reported only with those procedures not listed in Appendix G of the CPT. Appendix G, Summary of CPT Codes That Include Moderate (Conscious) Sedation, lists those procedures for which conscious sedation is an inherent part of the procedure itself.

• Reimbursement consists of anesthesia base units plus anesthesia time units multiplied by a conversion factor.

• 99100: anesthesia for patient of extreme age, under one year and over seventy.

• 99116: anesthesia complicated by utilization of total body hypothermia.

• 99135: anesthesia complicated by utilization of controlled hypotension.

• 99140: anesthesia complicated by emergency conditions (specify).

• 99143: Moderate sedation services (other than those services described by codes 00100-01999) provided by the same physician performing the diagnostic or therapeutic service that the 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; under 5 years of age, first 30 minutes intraservice time

• We do not provide separate reimbursement for postoperative epidural narcotic analgesia when performed on the same date of service as epidural anesthesia, since the primary reason for the catheter insertion is for the administration of the anesthetic. However, we do provide payment for daily hospital management under CPT code 01996 on the same day as when epidural anesthesia is administered for the surgical procedure.

• We do not provide separate reimbursement to an anesthesiologist for postoperative pain consultation when performed on the same date of service as the surgical procedure because usual pain management services are considered part of postoperative care and included in the anesthesia base units.

• We reimburse postoperative patient-controlled analgesia (PCA) only as an initial consultation when performed subsequent to the day of surgery. Report initial consultation (CPT code 99252), 1 unit of service only. Report CPT code 99252 only once during a hospital admission.

• Reimbursement for a pre-operative consultation that is rendered within one to ten days prior to the date of surgery is already included in the global allowance for the administration of anesthesia. However, if an interval exceeding ten days elapses between a routine pre-operative consultation and the date of surgery, due to surgical rescheduling or cancellation, then the initial pre-operative evaluation can be reimbursed as a limited consultation.

• Bill a single epidural injection of narcotics using CPT code 62310 or 62311 and 1 unit of service.

• Bill an epidural catheter insertion for the continuous administration of narcotics using CPT code 62318 or 62319 and 1 unit of service.

• Effective 01/01/04 according to CPT 2004, CPT code 01996 to report daily hospital management of continuous epidural or subarachnoid drug administration performed after insertion of an epidural or subarachnoid catheter.

• Do not bill CPT codes 62310-62319 on the day of surgery when the epidural injection is performed primarily for the surgical anesthetic and not for the postoperative narcotic. CPT code 01996 (daily hospital management) may be billed if the record demonstrates that the anesthesiologists’ administration of the agent required patient care substantially beyond the intraoperative and normal recovery period.

• Do not bill 01996 (daily hospital management) on the same date of service as 62310 – 62319.

• Bill anesthesia for electroconvulsive therapy (ECT) with CPT code 00104. One unit of service is allowed.

• Bill for Swan-Ganz catheter insertion using CPT code 93503.

• Bill the insertion of epidural or intrathecal catheter for narcotic infusion for intractable pain due to malignant disease requiring laminectomy with CPT code 62351 and without laminectomy with CPT code 62350. 

NESTHESIA FOR OBSTETRIC SERVICES - CPT 01960, 01967 - 01969

Delivery only codes:

• CPT code 01960 for anesthesia for vaginal delivery only.

• CPT code 01961 for anesthesia for cesarean delivery only.

Labor analgesia/anesthesia for vaginal or cesarean delivery codes:

• CPT code 01967 for neuraxial labor analgesia/anesthesia for planned vaginal delivery (List separately in addition to code for primary procedure performed).

Effective 9/1/04, we allow a maximum of 20 time units for CPT code 01967.

• CPT code 01968 for anesthesia for cesarean delivery following neuraxial labor analgesia/anesthesia (List separately in addition to code for primary procedure performed). Bill CPT 01968 in conjunction with CPT code 01967

Other codes:

• CPT code 01962 for anesthesia for urgent hysterectomy following delivery.

• CPT code 01963 for anesthesia for cesarean hysterectomy without any labor analgesia/anesthesia care.

• CPT code 01964 for anesthesia for abortion procedures.

• CPT code 01969 for anesthesia for cesarean hysterectomy following neuraxial labor analgesia/anesthesia (List separately in addition to code for primary procedure performed). 

Anesthesia Modifiers - P1 - P6 modifier

Anesthesia Modifiers Including Physical Status Modifiers:

All anesthesia services are reported by use of the anesthesia five-digit procedure code (00100-01999) plus the addition of a physical status modifier. The use of other optional modifiers may be appropriate.

Physical Status Modifiers

Physical Status modifiers are represented by the initial letter 'P' followed by a single digit from 1 to 6 defined below:

P1 - A normal healthy patient.

P2 - A patient with mild systemic disease.

P3 - A patient with severe systemic disease.

P4 - A patient with severe systemic disease that is a constant threat to life.

P5 - A moribund patient who is not expected to survive without the operation.

P6 - A declared brain-dead patient whose organs are being removed for donor purposes.

The above six levels are consistent with the American Society of Anesthesiologists (ASA) ranking of patient physical status. Physical status is included in CPT to distinguish between various levels of complexity of the anesthesia service provided.

Example: 00100-P1

Other Modifiers (Optional) Under certain circumstances, medical services and procedures may need to be further modified. Other modifiers commonly used in Anesthesia are included below. A complete list of modifiers and their respective codes are listed in Appendix A.

-22 Unusual Procedural Services: When the service(s) provided is greater than that usually required for the listed procedure, it may be identified by adding modifier '-22' to the usual procedure number or by use of the separate five digit modifier code 09922. A report may also be appropriate.

-23 Unusual Anesthesia: Occasionally, a procedure which usually requires either no anesthesia or local anesthesia, because of unusual circumstances must be done under general anesthesia. This circumstance may be reported by adding the modifier '-23' to the procedure code of the basic service or by use of the separate five digit modifier code 09923. 

Note: Modifier '-47', Anesthesia by Surgeon, (see modifier section) would not be used as a modifier for the anesthesia procedures 00100- 01999.

-32 Mandated Services: Services related to mandated consultation and/or related services (eg, PRO, 3rd party payer) may be identified by adding the modifier '-32' to the basic procedure, or the service may be reported by use of the five digit modifier 09932.

Anesthesia Modifiers - P1 - P6 modifier

Anesthesia Modifiers Including Physical Status Modifiers:

All anesthesia services are reported by use of the anesthesia five-digit procedure code (00100-01999) plus the addition of a physical status modifier. The use of other optional modifiers may be appropriate.

Physical Status Modifiers

Physical Status modifiers are represented by the initial letter 'P' followed by a single digit from 1 to 6 defined below:

P1 - A normal healthy patient.

P2 - A patient with mild systemic disease.

P3 - A patient with severe systemic disease.

P4 - A patient with severe systemic disease that is a constant threat to life.

P5 - A moribund patient who is not expected to survive without the operation.

P6 - A declared brain-dead patient whose organs are being removed for donor purposes.

The above six levels are consistent with the American Society of Anesthesiologists (ASA) ranking of patient physical status. Physical status is included in CPT to distinguish between various levels of complexity of the anesthesia service provided.

A report may also be appropriate.-23 Unusual Anesthesia: Occasionally, a procedure which usually requires either no anesthesia or local anesthesia, because of unusual circumstances must be done under general anesthesia. This circumstance may be reported by adding the modifier '-23' to the procedure code of the basic service or by use of the separate five digit modifier code 09923. 

Anesthesia Billing form Guidelines

Prior Authorization

Anesthesia itself does not require prior authorization; however, prior authorization may be required for the related surgical procedure or service.

Time-Based Units

During the first 4 hours of service, 15 minutes equals 1 unit. If services are provided for longer than 4 hours in one occurrence, each 10-minute period after the initial 4 hours equals 1 unit. A period less than a unit should be rounded up to the next unit.

Example A: 5 hours or 300 minutes equals 22 units – 16 units for the first 4 hours (1 unit per each 15 minutes) and 6 units for the last hour (1 unit per each 10 minutes).

Example B: 128 minutes is billed as 9 units (8 units for the first 120 minutes and 1 additional unit for the remaining 8 minutes).

Completing the Claim Form

· Field 19: When billing a time-based code,enter the total minutes of reportable anesthesia time in Field 19.

· Field 24D: On the bottom, white half of the claim line, enter one CPT code and one physical status modifier (P1-P6). List additional modifiers when appropriate

· Field 24G:

o When using a time-based code, enter the number of reportable anesthesia time units; do not add base units or modifier units to the time units.

o When using an occurrence-based code, enter a “1” for each occurrence. The following codes are paid per occurrence: 01953, 01967, 01968, 01969, 01996, 99100, 99116, 99135 and 99140.

CPT Code 99140 Medicaid carefully monitors for the appropriate use of code 99140 and modifiers P3, P4 and P5. Providers’ in-office records must verify medical necessity of this procedure.

Code 99140 should be used only for emergency conditions. This does not include a normal delivery or use of an epidural during delivery.

Anesthesia services: general, local, regional, epidural:

• We do not provide separate or additional reimbursement for the usual monitoring procedures that are traditionally part of and recorded on the anesthesia record because they are considered an integral part of anesthesia services and are included in the anesthesia base unit value. Unusual forms of monitoring (eg, intra-arterial, central venous and Swan-Ganz) are not included and may be billed separately.

• We do not provide separate or additional reimbursement for local anesthesia because it is considered part of the surgical procedure or other manipulation for which it is given.

• Moderate sedation services provided by the same physician performing the diagnostic or therapeutic service that the sedation supports should be reported with CPT codes 99143-99145.

Separate or additional reimbursement for moderate sedation services submitted with codes 99143-99145 is allowed according to CPT coding guidelines and should be reported only with those procedures not listed in Appendix G of the CPT. Appendix G, Summary of CPT Codes That Include Moderate (Conscious) Sedation, lists those procedures for which conscious sedation is an inherent part of the procedure itself.

• Reimbursement consists of anesthesia base units plus anesthesia time units multiplied by a conversion factor.

• 99100: anesthesia for patient of extreme age, under one year and over seventy.

• 99116: anesthesia complicated by utilization of total body hypothermia.

• 99135: anesthesia complicated by utilization of controlled hypotension.

• 99140: anesthesia complicated by emergency conditions (specify).

• 99143: Moderate sedation services (other than those services described by codes 00100-01999) provided by the same physician performing the diagnostic or therapeutic service that the 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; under 5 years of age, first 30 minutes intraservice time

• We do not provide separate reimbursement for postoperative epidural narcotic analgesia when performed on the same date of service as epidural anesthesia, since the primary reason for the catheter insertion is for the administration of the anesthetic. 

However, we do provide payment for daily hospital management under CPT code 01996 on the same day as when epidural anesthesia is administered for the surgical procedure.

• We do not provide separate reimbursement to an anesthesiologist for postoperative pain consultation when performed on the same date of service as the surgical procedure because usual pain management services are considered part of postoperative care and included in the anesthesia base units.

• We reimburse postoperative patient-controlled analgesia (PCA) only as an initial consultation when performed subsequent to the day of surgery. Report initial consultation (CPT code 99252), 1 unit of service only. Report CPT code 99252 only once during a hospital admission.

• Reimbursement for a pre-operative consultation that is rendered within one to ten days prior to the date of surgery is already included in the global allowance for the administration of anesthesia. 

However, if an interval exceeding ten days elapses between a routine pre-operative consultation and the date of surgery, due to surgical rescheduling or cancellation, then the initial pre-operative evaluation can be reimbursed as a limited consultation.

• Bill a single epidural injection of narcotics using CPT code 62310 or 62311 and 1 unit of service.

• Bill an epidural catheter insertion for the continuous administration of narcotics using CPT code 62318 or 62319 and 1 unit of service.

• Effective 01/01/04 according to CPT 2004, CPT code 01996 to report daily hospital management of continuous epidural or subarachnoid drug administration performed after insertion of an epidural or subarachnoid catheter.

• Do not bill CPT codes 62310-62319 on the day of surgery when the epidural injection is performed primarily for the surgical anesthetic and not for the postoperative narcotic. CPT code 01996 (daily hospital management) may be billed if the record demonstrates that the anesthesiologists’ administration of the agent required patient care substantially beyond the intraoperative and normal recovery period.

• Do not bill 01996 (daily hospital management) on the same date of service as 62310 – 62319.

• Bill anesthesia for electroconvulsive therapy (ECT) with CPT code 00104. One unit of service is allowed.

• Bill for Swan-Ganz catheter insertion using CPT code 93503.

• Bill the insertion of epidural or intrathecal catheter for narcotic infusion for intractable pain due to malignant disease requiring laminectomy with CPT code 62351 and without laminectomy with CPT code 62350. 

ANESTHESIA FOR OBSTETRIC SERVICES - CPT 01960, 01967 - 01969

Delivery only codes:

• CPT code 01960 for anesthesia for vaginal delivery only.

• CPT code 01961 for anesthesia for cesarean delivery only. Labor analgesia/anesthesia for vaginal or cesarean delivery codes:

• CPT code 01967 for neuraxial labor analgesia/anesthesia for planned vaginal delivery (List separately in addition to code for primary procedure performed).

Effective 9/1/04, we allow a maximum of 20 time units for CPT code 01967.

• CPT code 01968 for anesthesia for cesarean delivery following neuraxial labor analgesia/anesthesia (List separately in addition to code for primary procedure performed). Bill CPT 01968 in conjunction with CPT code 01967

Other codes:

• CPT code 01962 for anesthesia for urgent hysterectomy following delivery.

• CPT code 01963 for anesthesia for cesarean hysterectomy without any labor analgesia/anesthesia care.

• CPT code 01964 for anesthesia for abortion procedures.

• CPT code 01969 for anesthesia for cesarean hysterectomy following neuraxial labor analgesia/anesthesia (List separately in addition to code for primary procedure performed).