Mountain State Medical Policy Bulletin
Section: Anesthesia
Number: A-8
Topic: Payment for Anesthesia Services
Effective Date: August 1, 2005
Issued Date: August 1, 2005
Date Last Reviewed: 07/2005

General Policy Guidelines

Indications and Limitations of Coverage

The following types of anesthesia qualify for payment as anesthesia services:

  1. Inhalation

  2. Regional
    1. Spinal (low spinal, saddle block)
    2. Epidural (caudal)
    3. Nerve block (retrobulbar, brachial plexus block, etc.)
    4. Field block

  3. Intravenous

  4. Rectal

  5. Conscious sedation

In addition, anesthesia for diagnostic or therapeutic nerve blocks and injections (01991, 01992)(when the block or injection is performed by a different provider) is eligible for payment.

Local anesthesia (A9270), which is direct infiltration of the incision, wound, or lesion is not a covered service.

Payment for anesthesia services is evaluated through the use of relative values. Basic unit values have been assigned to most procedures and reflect the difficulty of the anesthesia services including the usual pre-operative and post-operative care and evaluation. When anesthesia is reported, the service should be reported processed under the appropriate CPT anesthesia procedure code. In addition, when a surgical procedure is reported for which no base units have been assigned, a minimum of three base units will be assigned to the anesthesia service.

Payment for anesthesia services is evaluated according to the basic unit value, plus time units reported, plus eligible modifying units when appropriate, multiplied by a monetary conversion factor. (See Medical Policy Bulletin A-11 for additional information on modifying units and procedure codes.)

The basic value for anesthesia when multiple surgical procedures are performed is the basic value for the procedure with the highest unit value. No payment is allowed for the basic unit value of a second, third, etc., procedure.

Anesthesia time begins when the anesthesiologist is first in attendance with the patient for the purpose of creating the anesthetic state, and ends when he is no longer in personal attendance (that is, when the patient may be safely placed under the customary post-operative supervision). This time must be documented on the anesthesia record.

When calculating time units for the time actually spent administering anesthesia, each fifteen (15) minute segment or fraction thereof should be considered one time unit.

Procedure Codes

0199101992J0670J2001J2795S0020

Traditional Guidelines

Refer to General Policy Guidelines

FEP Guidelines

Local anesthesia (01991, 01992, J0670, J2001, J2795, S0020) is covered.

Also refer to General Policy Guidelines

PPO Guidelines

Refer to General Policy Guidelines

Managed Care POS Guidelines

Refer to General Policy Guidelines

Publications

References

View Previous Versions

No Previous Versions

Table Attachment

Text Attachment

Procedure Code Attachment


Glossary




This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Medical policies are designed to supplement the terms of a member's contract. The member's contract defines the benefits available; therefore, medical policies should not be construed as overriding specific contract language. In the event of conflict, the contract shall govern.

Medical policies do not constitute medical advice, nor the practice of medicine. Rather, such policies are intended only to establish general guidelines for coverage and reimbursement under Mountain State Blue Cross Blue Shield plans. Application of a medical policy to determine coverage in an individual instance is not intended and shall not be construed to supercede the professional judgment of a treating provider. In all situations, the treating provider must use his/her professional judgment to provide care he/she believes to be in the best interest of the patient, and the provider and patient remain responsible for all treatment decisions.

Mountain State Blue Cross Blue Shield (MSBCBS) retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of MSBCBS. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.