Reimbursement and Billing Guidelines for Anesthesia Claims

Anesthesia claim guidelines
Anesthesia services may be submitted for reimbursement using CPT-4 codes or American Society of Anesthesia (ASA) codes.

Anesthesia claim modifiers
Horizon Blue Cross Blue Shield of New Jersey reimburses for anesthesia services billed with modifiers in accordance with the guidelines provided by:

• The Centers for Medicare & Medicaid Services’ (CMS) MedicareClaims Processing Manual.

• New Jersey Administrative Code (8:43G-6.3, 8:43A-12.4-5, 13:35-4A.8-11).

Physicians must report the appropriate anesthesia modifier to denote whether the service was personally performed, medically directed or medically supervised. Specific anesthesia modifiers are identified in MedicareClaims Processing Manual, Chapter 12 – Physicians/Nonphysician Practitioners.

Anesthesia reimbursement calculation
Horizon BCBSNJ reimburses for anesthesia services based on the following formula:

(Base Value Units+Time Units)xConversion Factor=Reimbursement

• Base Value Units: Each CPT code is assigned a base value unit.
• Time Units: See the following section for instructions on calculating time units.
• Conversion Factor: Horizon BCBSNJ’s fixed fee for anesthesia reimbursement.

Each CPT code is assigned a base value unit. See the following section for instructions on calculating time units. Horizon BCBSNJ’s fixed fee for anesthesia reimbursement. Total anesthesia reimbursement.

Time and anesthesia claims
When submitting anesthesia claims electronically, please use one of the three qualifiers within the table below to identify the type of units being submitted.

Our claims processing system calculates time units based on the total time that anesthesia was provided. Time units are calculated in 15-minute intervals. Our system will round additional time greater than eight minutes up to the next unit. Our system will round down additional time seven and fewer minutes. For example:

• 30 minutes of anesthesia is equal to two units (30=15+15)

• 38 minutes of anesthesia is rounded up to three units (38=15+15+8)

• 37 minutes of anesthesia is rounded down to two units (37=15+15+7)

Anesthesia for vaginal and cesarean section deliveries
Anesthesia for deliveries may follow unique rules, based on the type of delivery performed.

• Anesthesia for normal vaginal delivery is reimbursed based on a flat case rate (rates vary per geographic region).

• Cesarean section delivery is reimbursed based on a time calculation.

• A normal vaginal delivery that becomes a cesarean section delivery is reimbursed at a special rate that combines both a case rate plus a time calculation.

Horizon BCBSNJ reserves the right to change our obstetric reimbursement methodology.

Certified Registered Nurse Anesthetist (CRNA)
Anesthesia services provided by a CRNA are eligible for reimbursement provided that the CRNA is employed by, or under the supervision of, an anesthesiologist.

When billing Horizon BCBSNJ for services rendered, submit your full charges for the applicable CPT-4 codes on both the CRNA claim line and the anesthesiologist claim line. Do not split the total charge between the CRNA and the anesthesiologist. Our systems will adjudicate the claim lines to calculate 50 percent of our allowance for both the CRNA and the supervising anesthesiologist for the service provided.

Please also append the claim lines with the appropriate modifier as indicated in the table below:

Claim payment, as always, is subject to all member and group benefit limitations, conditions and exclusions.

We hope this information helps to clarify our anesthesia claim processing guidelines. If you have questions, please call Physician Services at 1-800-624-1110 or contact your Network Specialist.