Effective Date: April 1, 2021

Purpose:
To provide guidelines for the reimbursement of anesthesia services for professional providers.

Scope:
Products included:

• NJ FamilyCare/Medicaid
• Fully Integrated Dual Eligible Special Needs Program (FIDE-SNP)

Definitions:

• Anesthesia: The administration of a drug or anesthetic agent by an anesthesiologist in order for a patient to obtain muscular relaxation and partial or total loss of sensation and/or consciousness.
• Anesthesia Time: The actual number of anesthesia minutes as reported on the claim.
• Base Unit Value: Each anesthesia code is assigned a base unit value by the American Society of Anesthesiologists (ASA) and used for the purpose of establishing fee schedule allowances. Anesthesia services are paid on the basis of a relative value system, which include both base and actual time units. Base units take into account the complexity, risk, and skill required to perform the service.
• Base Unit: Value for each anesthesia code that reflects all activities other than anesthesia time. Anesthesia activities include usual pre-operative and post-operative visits, the administration of fluids or blood incident to anesthesia care, and monitoring services.

Policy:
Anesthesia services must be reported using the appropriate procedure code from the anesthesia section of the Current Procedural Terminology (CPT®) book, procedure codes 00100-01999.

Time Reporting:
Consistent with CMS guidelines, Horizon NJ Health requires time-based anesthesia services to be reported with actual anesthesia time in one-minute increments. For example, if the anesthesia time is one hour, then 60 minutes should be submitted.

Every 15-minute interval will be converted by Horizon NJ Health into 1 unit, rounding up to the next unit for 8 to 14 minutes, rounding down for 1 to 7 minutes.

• If the remainder of minutes is 7.99 or less, round the unit down.
• If the remainder of minutes is 8.00 or more, round the unit up.

Anesthesia time begins when the anesthetist begins to prepare the patient for the induction of anesthesia in the operating room or in an equivalent area and ends when the anesthetist is no longer in personal attendance, that is, when the patient may be safely placed under post-anesthetic supervision. The anesthesia log should document the exact start and end time for the anesthesia.

Reimbursement Formula:
Time-based anesthesia services are reimbursed according to the following formula:
(Time Units + Base Units) x Conversion Factor = Allowance

Anesthesia Modifiers:
All anesthesia services must be reported by use of anesthesia 5 digit procedure code (From range 00100-01999) plus the appropriate anesthesia modifier(s). The anesthesia HCPCS modifier should be used in the first modifier position. Anesthesia codes billed without a HCPCS modifier shall not be considered for reimbursement. Reimbursement guidelines for the anesthesia modifiers are noted below and would be applied to the Horizon NJ Health anesthesia allowance:

The Modifiers listed below, QS, G8 and G9, are informational only, and do not affect reimbursement. Informational modifiers must be used in the second modifier position when billed in conjunction with a pricing anesthesia modifier (which must be submitted in the primary modifier position). Claims submitted with the informational modifier(s) without a valid primary anesthesia modifier will be denied.

• QS – Monitored anesthesia care service (MAC);
• G8 – MAC for deep complex complicated or markedly invasive surgical procedures and may be used in lieu of modifier QS.
• G9 – MAC for a patient who has a history of severe cardiopulmonary condition and may be used in lieu of modifier QS.

Multiple Anesthesia Services:
When multiple surgical procedures are rendered during the same operative session, only one procedure code with the highest anesthesia base unit value shall be used in calculating and billing the anesthesia allowance. The time reported is the total combined time for all procedures performed on the same patient during the same operative session.

Duplicate Anesthesia Services:
Duplicate anesthesia services submitted by the same physician (or physician group), different physician or other qualified health care professional for the same patient on the same date of service will be denied. Horizon NJ Health will only consider for reimbursement the first claim submission of that code.

Procedure:
Horizon NJ Health will consider for reimbursement anesthesia services using a code from range 00100-01999 when appended with a required anesthesia modifier in the first modifier position as follows:

• Anesthesia services billed with modifier –AA shall be considered for reimbursement at 100% of the applicable fee schedule.
• Anesthesia services billed with modifier –AD, -QK, -QX or –QY shall be considered for reimbursement at 50% of the applicable fee schedule.

Horizon NJ Health will not consider for reimbursement anesthesia services billed with modifier –QZ.

Horizon NJ Health will not consider for reimbursement anesthesia services billed without a required pricing anesthesia modifier in the first modifier position.

Horizon NJ Health will not consider for reimbursement anesthesia service time units that are not documented appropriately within the medical record.

Resources:
Medicare Claims Processing Manual, Chapter 12- Physicians/Nonphysician Practitioners
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c12.pdf

New Jersey Administrative Code, Title 10 Human Services, Chapter 54 Physician Services, Subchapter 2,
https://www.state.nj.us/humanservices/providers/rulefees/regs/NJAC%2010_54%20Physician%20Services.pdf

American Medical Association, Current Procedural Terminology (CPT®) and associated publications and services

Limitations and Exclusions:
Notwithstanding the foregoing, all payment determinations are subject to all other, applicable limitations, including but not limited to, the following:

• Benefit Limitations
• The terms of any applicable provider participation agreement;
• Routine claim editing logic, including but not limited to incidental or mutually exclusive logic;
• Medical necessity; and
• Applicable law, regulatory guidance, government mandates, and the terms of the Managed Care Contract between Horizon NJ Health and the New Jersey Department of Human Services, Division of Medical Assistance and Health Services.

CPT Copyright 2017 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association. The CPT codes and nomenclature used in this Policy are subject to revision and/or change by the American Medical Association. In the event of such changes, the Policy will continue to be in force, albeit applied to the new or amended coding so issued until such time as the Policy is reviewed and updated to reflect the new or amended coding.