Anesthesia Reimbursement

Policy No: 102
Date of Origin: 05/01/2010
Section: Anesthesia
Last Reviewed: 07/01/2019
Last Revised: 07/01/2019
Approved: 07/01/2019
Effective: 08/01/2019

This policy applies only to physicians and other qualified health care professionals.

Definitions

Anesthesia
The administration of a drug or anesthetic agent by an anesthesiologist or Certified Registered Nurse Anesthetist (CRNA) for medical or surgical purposes to obtain muscular relaxation, induce partial or total loss of sensation and/or consciousness.

Base Units
Units of reimbursement designed to reflect the relative complexity of various anesthesia services. Our health plan uses Base Units documented in the current edition of Relative Value Guide® Book A Guide for Anesthesia Values published by the American Society of Anesthesiologists.

Modifiers P1 through P6
Modifiers used with anesthesia codes that reflect the physical status of the patient receiving anesthesia. Our health plan assigns unit values to certain physical status modifiers, as shown below:

Modifier and Physical Status Units
P1 — A normal healthy patient
Physical Status Units — 0
P2 — A patient with mild systemic disease
Physical Status Units — 0
P3 — A patient with severe systemic disease
Physical Status Units — 1
P4 — A patient with severe systemic disease that is a constant threat to life
Physical Status Units — 2
P5 — A moribund patient who is not expected to survive without the operation
Physical Status Units — 3
P6 — A declared brain-dead patient whose organs are being removed for donor purposes
Physical Status Units — 0

Modifiers GC and QK
Modifiers used by physicians when supervising residents or student nurse anesthetists.
GC — Service performed by resident under direction of a teaching physician
QK — Medical direction of 3 or 4 concurrent anesthesia procedures

Modifiers QX and QY
Modifiers used with anesthesia codes that identify services provided by a licensed CRNA with medical direction by a physician.
QX — CRNA service: with medical direction by a physician
QY — Medical direction of one CRNA by an anesthesiologist

Time Units
The time starting when the anesthesiologist or CRNA begins to prepare the patient for anesthesia care in the operating room or equivalent area, and ending when the anesthesiologist or CRNA is no longer in personal attendance, that is, when the patient is safely placed under post-anesthesia supervision.

This time is billed in minutes. The minutes are then divided into increments used in calculating anesthesia reimbursement. Our health plan uses 15 minute increments; 4 units per hour. Increments of less than 15 minutes will count as 1 unit.

Example: Anesthesia time is billed as 80 minutes. Time units are 6 units (5 units * 15 minutes = 75 minutes. The remaining 5 minutes are assigned 1 unit.

Disclaimer

Your use of this Reimbursement Policy constitutes your agreement to be bound by and comply with the terms and conditions of the Reimbursement Policy Disclaimer.