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UnitedHealthcare OxfordReimbursement PolicyANESTHESIA POLICY (CES)Policy Number: ADMINISTRATIVE 269.1 T0Table of ContentsPageINSTRUCTIONS FOR USE . 1APPLICABLE LINES OF BUSINESS/PRODUCTS . 1APPLICATION . 1OVERVIEW . 1REIMBURSEMENT GUIDELINES . 2DEFINITIONS . 6QUESTIONS AND ANSWERS . 8APPLICABLE CODES . 10REFERENCES . 12POLICY HISTORY/REVISION INFORMATION . 13Effective Date: January 1, 2020Related Policies Refer to the Reimbursement Guidelines section ofthe policyINSTRUCTIONS FOR USEThe services described in Oxford policies are subject to the terms, conditions and limitations of the member's contractor certificate. Unless otherwise stated, Oxford policies do not apply to Medicare Advantage members. Oxford reservesthe right, in its sole discretion, to modify policies as necessary without prior written notice unless otherwise requiredby Oxford's administrative procedures or applicable state law. The term Oxford includes Oxford Health Plans, LLC andall of its subsidiaries as appropriate for these policies.Certain policies may not be applicable to Self-Funded members and certain insured products. Refer to the memberspecific benefit plan document or Certificate of Coverage to determine whether coverage is provided or if there areany exclusions or benefit limitations applicable to any of these policies. If there is a difference between any policy andthe member specific benefit plan document or Certificate of Coverage, the member specific benefit plan document orCertificate of Coverage will govern.UnitedHealthcare may also use tools developed by third parties, such as the MCG Care Guidelines, to assist us inadministering health benefits. The MCG Care Guidelines are intended to be used in connection with the independentprofessional medical judgment of a qualified health care provider and do not constitute the practice of medicine ormedical advice.APPLICABLE LINES OF BUSINESS/PRODUCTSThis policy applies to Oxford Commercial plan membership.APPLICATIONThis reimbursement policy applies to services reported using the 1500 Health Insurance Claim Form (a/k/a CMS-1500)or its electronic equivalent or its successor form. This policy applies to all network and non-network physicians andother qualified health care professionals, including, but not limited to, non-network authorized and percent of chargecontract physicians and other qualified health care professionals.OVERVIEWOxford's reimbursement policy for anesthesia services is developed in part using the American Society ofAnesthesiologists (ASA) Relative Value Guide (RVG ), the ASA CROSSWALK , and Centers for Medicare and MedicaidServices (CMS) National Correct Coding Initiative (NCCI) Policy Manual, CMS NCCI edits and the CMS NationalPhysician Fee Schedule.Current Procedural Terminology (CPT ) codes and modifiers and Healthcare Common Procedure Coding System(HCPCS) modifiers identify services rendered. These services may include, but are not limited to, general or regionalanesthesia, Monitored Anesthesia Care, or other services to provide the patient the medical care deemed optimal.Anesthesia Policy (CES)UnitedHealthcare Oxford Reimbursement Policy 1996-2020, Oxford Health Plans, LLCPage 1 of 13Effective 01/01/2020

The Anesthesia Policy addresses reimbursement of procedural or pain management services that are an integral partof anesthesia services as well as anesthesia services that are an integral part of procedural services.REIMBURSEMENT GUIDELINESAnesthesia ServicesAnesthesia services must be submitted with a CPT anesthesia code in the range 00100-01999, excluding 01953 and01996, and are reimbursed as time-based using the Standard Anesthesia Formula. Refer to the Anesthesia Codes listfor all applicable codes.For purposes of this policy the code range 00100-01999 specifically excludes 01953 and 01996 when referring toanesthesia services. CPT codes 01953 and 01996 are not considered anesthesia services because, according to theASA RVG , they should not be reported as time-based services.ModifiersModifierNotes/DescriptionAll anesthesia services including Monitored Anesthesia Care mustbe submitted with a required anesthesia modifier in the firstmodifier position. These modifiers identify whether a procedurewas personally performed, medically directed, or medicallysupervised. Consistent with CMS, UnitedHealthcare will adjust theAllowed Amount by the Modifier Percentage indicated in the tablebelow.ReimbursementPercentageAAAnesthesia services performed personally by an anesthesiologist100%ADMedical supervision by a physician: more than four concurrentanesthesia procedures. *For additional information, refer toStandard Anesthesia Formula with Modifier AD underReimbursement Formula100%QKMedical direction of two, three, or four concurrent anesthesiaprocedures involving qualified individuals50%QXQualified nonphysician anesthetist with medical direction by aphysician50%QYMedical direction of one qualified nonphysician anesthetist by ananesthesiologist50%QZCRNA service; without medical direction by a physician100%These CPT and HCPCS modifiers may be reported to identify analtered circumstance for anesthesia and pain management.Additional rs22Increased Procedural Services59Distinct Procedural Service76Repeat Procedure or Service by Same Physician or Other QualifiedHealth Care Professional77Repeat Procedure by Another Physician or Other Qualified HealthCare Professional78Unplanned Return to the Operating/Procedure Room by the SamePhysician or Other Qualified Health Care Professional FollowingInitial Procedure for a Related Procedure During the PostoperativePeriod79Unrelated Procedure or Service by the Same Physician or OtherQualified Health Care Professional During the Postoperative PeriodXESeparate encounter: a service that is distinct because it occurredduring a separate encounterXUUnusual non-overlapping service: the use of a service that isdistinct because it does not overlap usual components of the mainserviceAnesthesia Policy (CES)UnitedHealthcare Oxford Reimbursement Policy 1996-2020, Oxford Health Plans, LLCAdditional InformationSee Questions and Answerssection, Q&A #9Page 2 of 13Effective 01/01/2020

ModifierNotes/DescriptionCPT and ASA guidelines identify six levels of ranking for patientphysical status. Appending a physical status modifier to a timebased anesthesia code identifies the level of complexity andModifying Unit(s) are added to the Base Unit Value for the mostcomplex situations. If more than one physical status modifier (P3,P4, or P5) is submitted, the modifier with the highest number ofunits is the reimbursable service.Modifying Units Added tothe Base Unit ValueP1A physical status modifier for a normal healthy patient0 unitsP2A physical status modifier for a patient with mild systemic disease0 unitsP3A physical status modifier for a patient with severe systemicdisease1 unitP4A physical status modifier for a patient with severe systemicdisease that is a constant threat to life2 unitsP5A physical status modifier for a moribund patient who is notexpected to survive without the operation3 unitsP6A physical status modifier for a declared brain-dead patient whoseorgans are being removed for donor purposes0 If reporting CPT modifier 23 or 47 or HCPCS modifier GC, G8, G9or QS then no additional reimbursement is allowed above theusual fee for that service.Additional InformationReimbursement23Unusual AnesthesiaNo additional: This isconsidered an informationalmodifier only.47Anesthesia by SurgeonNo additional: This isconsidered an informationalmodifier only.GCThis service has been performed in part by a resident under thedirection of a teaching physicianNo additional: This isconsidered an informationalmodifier only.Monitored Anesthesia Care (MAC) for deep complex, complicated,or markedly invasive surgical procedureNo additional: This isconsidered an informationalmodifier only which should bebilled along with a requiredanesthesia modifier and notbe in the first modifierpositionMonitored Anesthesia Care (MAC) for patient who has a history ofsevere cardiopulmonary conditionNo additional: This isconsidered an informationalmodifier only which should bebilled along with a requiredanesthesia modifier and notbe in the first modifierpositionQSMonitored anesthesiology care services (can be billed by aqualified nonphysician anesthetist or a physician)No additional: This isconsidered an informationalmodifier only which should bebilled along with a requiredanesthesia modifier and notbe in the first modifierpositionXPSeparate practitioner: a service that is distinct because it wasperformed by a different practitionerXSSeparate structure: a service that is distinct because it wasperformed on a separate organ/structureG8G9Anesthesia Policy (CES)UnitedHealthcare Oxford Reimbursement Policy 1996-2020, Oxford Health Plans, LLCPage 3 of 13Effective 01/01/2020

Reimbursement FormulaBase Values: Each CPT anesthesia code is assigned a Base Value by the ASA, and Oxford uses these values fordetermining reimbursement. The Base Value of each code is comprised of units referred to as the Base Unit Value.Time Reporting: Consistent with CMS guidelines, Oxford requires time-based anesthesia services be reported withactual Anesthesia Time in one-minute increments. For example, if the Anesthesia Time is one hour, then 60 minutesshould be submitted.Reimbursement Formulas: Time-based anesthesia services are reimbursed according to the following formulas: Standard Anesthesia Formula without Modifier AD* ([Base Unit Value Time Units Modifying Units] xConversion Factor) x Modifier Percentage. Standard Anesthesia Formula with Modifier AD* ([Base Unit Value of 3 1 Additional Unit if anesthesianotes indicate the physician was present during induction] x Conversion Factor) x Modifier Percentage.*For additional information, refer to Modifiers.Qualifying CircumstancesQualifying circumstances codes identify conditions that significantly affect the nature of the anesthetic serviceprovided. Qualifying circumstances codes should only be billed in addition to the anesthesia service with the highestBase Unit Value. The Modifying Units identified by each code are added to the Base Unit Value for the anesthesiaservice according to the above Standard Anesthesia Formula.CPT Code99100CPT Code DescriptionAnesthesia for patient of extreme age, younger than 1 year and olderthan 70 (List separately in addition to code for primary anesthesiaprocedure). (Per the ASA RVG an additional unit for 99100 is notallowed with anesthesia codes 00326, 00561, 00834 and 00836)Modifying Units1 unit99116Anesthesia complicated by utilization of total body hypothermia (Listseparately in addition to code for primary anesthesia procedure). (Perthe ASA RVG additional units for 99116 are not allowed withanesthesia codes 00561, 00562, 00563 and 00567)5 units99135Anesthesia complicated by utilization of controlled hypotension (Listseparately in addition to code for primary anesthesia procedure). (Perthe ASA RVG additional units for 99135 are not allowed withanesthesia codes 00561, 00562, 00563 and 00567)5 units99140Anesthesia complicated by emergency conditions (specify) (Listseparately in addition to code for primary anesthesia procedure). (Anemergency is defined as existing when delay in treatment of thepatient would lead to a significant increase in the threat to life orbody part.)2 unitsAdditional Information: Anesthesia when surgery has been cancelled: Refer to the Questions and Answers section, Q&A #3, for additionalinformation. For information on reporting Certified Registered Nurse Anesthetist (CRNA) services, refer to the Questions andAnswers section, Q&A #4.Multiple or Duplicate Anesthesia ServicesMultiple Anesthesia ServicesAccording to the ASA, when multiple surgical procedures are performed during a single anesthesia administration,only the single anesthesia code with the highest Base Unit Value is reported. The time reported is the combined totalfor all procedures performed on the same patient on the same date of service by the same or different physician orother qualified health care professional. Add-on anesthesia codes (01953, 01968 and 01969) are exceptions to thisand are addressed in the Anesthesia Services section and Obstetric Anesthesia Services section of this policy. Oxfordaligns with these ASA coding guidelines. Specific reimbursement percentages are based on the anesthesia modifier(s)reported.Duplicate Anesthesia ServicesWhen duplicate (same) anesthesia codes are reported by the same or different physician or other qualified health careprofessional for the same patient on the same date of service, Oxford will only reimburse the first submission of thatcode. However, anesthesia administration services can be rendered simultaneously by an MD and a CRNA during theAnesthesia Policy (CES)UnitedHealthcare Oxford Reimbursement Policy 1996-2020, Oxford Health Plans, LLCPage 4 of 13Effective 01/01/2020

same operative session, each receiving 50% of the Allowed Amount (as indicated in the Modifier Table above) byreporting modifiers QK or QY and QX.In the event an anesthesia administration service is provided during a different operative session on the same day asa previous operative session, Oxford will reimburse one additional anesthesia administration appended with modifier59, 76, 77, 78, 79, or XE. As with the initial anesthesia administration, only the single anesthesia code with thehighest Base Unit Value should be

Oxford's reimbursement policy for anesthesia services is developed in part using the American Society of Anesthesiologists (ASA) Relative Value Guide (RVG ), the ASA CROSSWALK , and Centers for Medicare and Medicaid Services (CMS) National Correct Coding Initiative (NCCI) Policy Manual, CMS NCCI edits and the CMS National Physician Fee Schedule.