Reimbursement policy update: Professional anesthesia services
Anthem Blue Cross (Anthem) allows reimbursement of anesthesia services rendered by professional providers for covered members. Reimbursement is based upon:
- The reimbursement formula for the allowance and time increments in accordance with CMS.
- Proper use of applicable modifiers.
Effective September 1, 2019, Anthem will recognize the following anesthesia modifier:
- Modifier 99: This denotes multiple modifiers under certain circumstances; two or more modifiers may be necessary to completely delineate a service. In such situations, Modifier 99 should be added to the basic procedure, and other applicable modifiers may be listed as part of the description of the service.
Anthem does not recognize Modifier AD or Modifier 23 as anesthesia modifiers. Anesthesia modifiers are appended to the applicable procedure code to indicate the specific anesthesia service or who performed the service. Modifiers identifying who performed the anesthesia service must be billed in the primary modifier field to receive appropriate reimbursement. Claims submitted for anesthesiology services without the appropriate modifier will be denied.
Anthem will continue to recognize the following anesthesia modifiers as well as physical status modifiers P3, P4 and P5:
- Modifier AA: anesthesiology service performed personally by an anesthesiologist — reimbursement is based on 100% of the applicable fee schedule or contracted/negotiated rate
- Modifier QK: medical direction of two, three or four concurrent anesthesia procedures involving qualified individuals — reimbursement is based on 50% of the applicable fee schedule or contracted/negotiated amount
- Modifier QX: qualified nonphysician anesthetist with medical direction by a physician — reimbursement is based on 50% of the applicable fee schedule or contracted/negotiated amount
- Modifier QY: anesthesiologist medically directs one certified registered nurse anesthetist (CRNA) — reimbursement is based on 50% of the applicable fee schedule or contracted/negotiated amount
- Modifier QZ: CRNA service without medical direction by a physician —reimbursement is based on 100% of the applicable fee schedule or contracted/negotiated amount
- Modifier 47: denotes regional or general anesthesia services provided by the surgeon performing the medical procedure; we do not allow reimbursement of anesthesia services by the provider performing the medical procedure (other than obstetrical — see Obstetrical Anesthesia section of this policy); therefore, it is not appropriate to bill Modifier 47 with anesthesia services
For additional information, please review the Professional Anesthesia Services reimbursement policy at https://mediproviders.anthem.com/ca.
June 2019 Anthem Blue Cross Provider Newsletter - California