Description: Enter the two-digit qualifier identifying the non-NPI number followed by the ID number. Do not enter a space, hyphen, or other separator between the qualifier and number. (See
Block 17a for listing of qualifiers and numbers.)
I. Specific CMS-1500 Claim Form Billing and Reimbursement Guidelines
Final reimbursement determinations are based on several factors, including but not limited to, Member eligibility on the date of service, Medical Appropriateness, code edits, applicable Member co-payments, coinsurance, deductibles, benefit plan exclusions/limitations, authorization/referral requirements and medical policy.
1. Anesthesia Billing and Reimbursement Guidelines
Anesthesia services provided by an anesthesiologist or CRNA can be categorized as follows: Administration of anesthesia
Qualifying circumstances for anesthesia such as:
- Anesthesia for patient of extreme age, under one year or over seventy - Anesthesia complicated by utilization of total body hypothermia - Anesthesia complicated by utilization of controlled hypotension - Anesthesia complicated by emergency conditions
Unusual forms of monitoring such as: - Intra-arterial
- Central venous - Swan-Ganz
- Transesophageal echocardiography (TEE)
Post operative pain management-placement of epidural
Post operative pain management-daily hospital management of epidural (continuous) or subarachnoid (continuous) drug administration
Anesthesia services provided by an anesthesiologist or CRNA should be billed according to the following guidelines:
• Anesthesia services provided by an anesthesiologist or CRNA should be billed on a CMS-1500/ANSI 837P.
• Anesthesia services provided on different dates of service should be billed on separate claim forms.
Administration of Anesthesia
Paper Claim Form - Block 24C (Type of Service)
Electronic Media Claim - Record FA0 Field No. 8.0 (Type of Service Code)
Administration of anesthesia must be billed with Type of Service code 07 (Anesthesia). Paper Claim Form - Block 24D (CPT®/HCPCS)
Electronic Media Claim - Record FA0 Field No. 9.0 (HCPCS Procedure Code)
Administration of anesthesia must be billed using the most appropriate CPT® code 00100-01995 or 01999 in effect for the date of service.
The anesthesia administration code includes the following: * Pre-operative visits and/or evaluations
* Routine post-operative visits to the recovery room
* The administration of fluids and/or blood products incident to the anesthesia care
* Interpretation of non-invasive monitoring (EKG, EEG, ECG, temperature, blood pressure, oximetry, capnography, and mass spectrometry).
Note: Services for the administration of anesthesia will be rejected or returned if billed using a CPT® code in the range10040-69979.
When multiple surgical procedures are performed during a single anesthetic administration, only the procedure with the highest Basic Value should be reported. Refer to the American Society of Anesthesiologist Relative Value Guide in effect for the date of service to determine the procedure with the highest Basic Value. This applies to vaginal deliveries and Cesarean Sections followed immediately by a hysterectomy.
Billing more than one anesthesia administration code for a single anesthetic administration may result in delay in reimbursement, rejection of charge(s) or return of claim.
Paper Claim Form - Block 24D (First Modifier)
Electronic Media Claim - Record FA0 Field No. 10.0 (HCPCS Modifier 1)
Anesthesia services must be billed using the most appropriate anesthesia modifier. Acceptable anesthesia modifiers are as follows:
Modifier Description
AA Anesthesia service performed personally by anesthesiologist
AD Medical supervision by a physician: more than 4 concurrent procedures
QK Medical direction of 2, 3 or 4 concurrent anesthesia procedures involving qualified individuals QX CRNA service: with medical direction by a physician
QY Anesthesiologist medically directs one CRNA
QZ CRNA service: without medical direction by a physician
Anesthesia administration services billed without an acceptable anesthesia modifier will be rejected or returned.
It is not appropriate to bill modifier 47 (Anesthesia by Surgeon) with CPTTM codes 00100-01999.
Paper Claim Form - Block 24D (Second Modifier)
Electronic Media Claim - Record FA0 Field No. 11.0 (HCPCS Modifier 2)
A physical status modifier may be billed in the second modifier field. Acceptable physical status modifiers are as follows:
Modifier Description
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
Paper Claim Form - Block 24G (Days or Units)
Anesthesia time begins when the anesthesiologist or CRNA begins to prepare the patient for anesthesia care in the operating room or in an equivalent area, and ends when the anesthesiologist or CRNA is no longer in personal attendance, that is, when the patient may be safely placed under post-anesthesia supervision.
In cases where there is a break in anesthesia (e.g., due to technique used, delay of surgeon, relief, multiple start and stop times, etc.) time should be reported by summing up the blocks of time around a break in continuous anesthesia care.
Anesthesia time must be reported in minutes. One minute equals one number of service (unit). Anesthesia time must not be converted to units. Conversion to units will result in an incorrect payment.
Electronic Media Claim - Record FA0 Field No. 18.0 (Units of Service) Administration of anesthesia should be billed with one unit.
Do not bill anesthesia minutes in this field.
Electronic Media Claim - Record FA0 Field No. 19.0 (Anesthesia Minutes)
Anesthesia time begins when the anesthesiologist or CRNA begins to prepare the patient for anesthesia care in the operating room or in an equivalent area, and ends when the anesthesiologist or CRNA is no longer in personal attendance, that is, when the patient may be safely placed under post-anesthesia supervision.
In cases where there is a break in anesthesia (e.g., due to technique used, delay of surgeon, relief, multiple start and stop times, etc.) time should be reported by summing up the blocks of time around a break in continuous anesthesia care.
Note: Anesthesia time must be reported in minutes. Anesthesia time must not be converted to units. Conversion to units will result in an incorrect payment.
If anesthesia time exceeds 0999 minutes, it is recommended a paper claim be submitted with the supplemental information such as the anesthesia flow sheet to ensure correct reimbursement.