Anesthesia Billing

BLUE CROSS AND BLUE SHIELD OF ARIZONA
PROFESSIONAL SERVICES PARTICIPATION AGREEMENT

REIMBURSEMENT EXHIBIT B
Specialty: Anesthesiology (MD/DOs)
The reimbursement set forth in this Exhibit B is the only payment required from
BCBSAZ, less applicable Subscriber Responsibility, if any , subject to the Coordination
of Benefi ts and Other Sources of Payment provisions of the Agreement.
For Subscribers covered under the products indicated in this Exhibit B, Provider shall
accept the following reimbursement terms :
[g] Indemnity [g] PPO [g] HMO
• As of the effective date of this Agreement: $72.00 per ASA unit.

• All other non-ASA unit reimbursement will be the lesser of: (i) one
hundred sixty percent (160%) of the applicable BCBSAZ Fee
Schedule, or (ii) one hundred percent (100%) of billed charges.
• Effective one (1) year from the date of this Agreement: $72.90 per ASA unit.
• All other non-ASA unit reimbursement will be the lesser of: (i) one
hundred sixty two percent (162%) of the applicable BCBSAZ Fee
Schedule, or (ii) one hundred percent (100%) of billed charges.
• Effective two (2) years from the date of this Agreement: $73.80 per ASA unit
• All other non-ASA unit reimbursement will be the lesser of: (i) one fl
re.,,,,.'
hundred sixty four percent (164%) of the applicable BCBSAZ Fee :.vr c,v
Schedule , or (ii) one hundred percent (100%) of billed charges.
[g] Medicare Supplement - Senior Preferred
As of the effective date of this Agreement , for Covered Services rendered to

Medicare Supplement Subscribers, BCBSAZ shall pay Provider the balance
payable after Medicare has made payment, up to the Medicare Allowed Amount.
For Covered Services rendered to Medicare Supplement Subscribers for which
Medicare does not make payment, BCBSAZ shall pay Provider the lesser of
billed charges or one hundred sixty percent (160%) of the applicable BCBSAZ
Fee Schedule.
Effective one year after Agreement effective date, for Covered Services rendered
to Medicare Supplement Subscribers , BCBSAZ shall pay Provider the balance
payable after Medicare has made payment, up to the Medicare Allowed Amount.
For Covered Services rendered to Medicare Supplement Subscribers for which
Medicare does not make payment, BCBSAZ shall pay Provider the lesser of
Rev1sed 3· 10·15, Printed 5/15/15, PROFESSIONAL AGRMT 3-10-15 LTR GRP.DOC
Fores! Country Anesthesia PC
28
•
billed charges or one hundred sixty two percent (162%) of the applicable
BCBSAZ Fee Schedule.
Effective two years after Agreement effective date, for Covered Services
rendered to Medicare Supplement Subscribers, BCBSAZ shall pay Provider the
balance payable after Medicare has made payment, up to the Medicare Allowed
Amount. For Covered Services rendered to Medicare Supplement Subscribers
for which Medicare does not make payment, BCBSAZ shall pay Provider the
lesser of billed charges or one hundred sixty four percent (164%) of the
applicable BCBSAZ Fee Schedule.
[&] Workers' Compensation
As of the effective date of this Agreement, for services rendered to employees

covered through the BCBSAZ Workers Compensation program, reimbursement
will be the lesser of: the applicable Industrial Commission of Arizona (ICA) fee,
billed charges, or one hundred sixty percent (160%) of the applicable BCBSAZ
Fee Schedule.
Effective one year after Agreement effective date, for services rendered to
employees covered through the BCBSAZ Workers Compensation program,
reimbursement will be the lesser of: the applicable Industrial Commission of
Arizona (ICA) fee, billed charges, or one hundred sixty two percent (162%) of the
Effective two years after Agreement effective date, for services rendered to
employees covered through the BCBSAZ Workers Compensation program,
reimbursement will be the lesser of: the applicable Industrial Commission of
Arizona (ICA) fee, billed charges, or one hundred sixty four percent (164%) of the
Exclusive Networks:
D Alliance network D Acclaim network D Select network
As of the effective date of this Agreement, for Covered Services rendered to

Subscribers covered under Benefit Plans that utilize the above exclusive
networks, BCBSAZ shall pay Provider the lesser of billed charges or one
hundred sixty percent (160%) of the applicable BCBSAZ Fee Schedule.
Effective one year after Agreement effective date, for Covered Services rendered
to Subscribers covered under Benefit Plans that utilize the above exclusive
networks, BCBSAZ shall pay Provider the lesser of billed charges or one
hundred sixty two percent (162%) of the applicable BCBSAZ Fee Schedule.
Revised 3-10-15, Printed 5/15/15, PROFESSIONAL AGRMT 3-10-15 LTA GAP.DOC

Forest Country Anesthesia PC
29
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Effective two years after Agreement effective date, for Covered Services
rendered to Subscribers covered under Benefit Plans that utilize the above
exclusive networks, BCBSAZ shall pay Provider the lesser of billed charges or
one hundred sixty four percent (164%) of the applicable BCBSAZ Fee Schedule.
Provider acknowledges the following:
BCBSAZ may periodically adjust the fee schedule as described in Section 9.02
BCBSAZ shall not lower fees, except on 30 days prior notice.
Provider has chosen to participate in the lines of business indicated in the boxes
checked above. If Provider is not contracted for a line of business, but chooses to
provide Covered Services to a Subscriber covered under that line of business, BCBSAZ
shall reimburse Provider according to the reimbursement terms for the line of business
for which Provider has contracted.
(The remainder of this page intentionally left blank)
Revised 3-10-15, Printed 5115/15, PROFESSIONAL AGRMT 3·10-15 LTR GAP.DOC

Forest Country Anesthe54a PC
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An Independent Licensee of the
Blue Cross and Blue Shield Association
PRICING GUIDELINES EFFECTIVE DATE: 12/1/2009

REVISION DATE: 7/1/2018
Changes: Clarification of billing time units
MATERNITY EPIDURAL ANESTHESIA
Coverage for services, procedures, medical devices and drugs are dependent upon benefit
eligibility as outlined in the member's specific benefit plan. This Pricing Guideline must be read in
its entirety to determine coverage eligibility, if any.
The section identified as "Description" defines or describes a service, procedure, medical device
or drug and is in no way intended as a statement of medical necessity and/or coverage.
The section identified as "Criteria" defines criteria to determine whether a service, procedure,
medical device or drug is considered medically necessary or experimental or investigational.
Pricing Guidelines are subject to change as new information becomes available.
Description:
Maternity epidural anesthesia, or neuraxial labor analgesia, represents regional anesthesia during labor
and delivery for either a vaginal or a Cesarean section delivery. The anesthesia provider places a catheter
into the epidural space of the spinal canal delivering analgesic/anesthetic medications that provide
adequate analgesia for labor and subsequent delivery.
Criteria:
The following reimbursement methodology will be used to assess and reimburse a claim for
maternity epidural anesthesia:
)- CPT Codes that identify maternity epidural anesthesia are: 01960, 01961, 01967, 01968.
)- Reimbursement methodology reflects:
Base Units + Modifier Units + Time Units = Total Units
Maternity Epidural PGL·External Page 1 of 5

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MATERNITY EPIDURAL ANESTHESIA (cont.)
Criteria: (cont.)
maternity epidural anesthesia: (cont.)
Base Units: The number of anesthesia base units will depend on the CPT Code being submitted
(01960, 01961, 01967, 01968). For appropriate base units, refer to the Provider Portal in
azblue.com and access the ASA Base Units Table located under Claims Management
Tab.
Modifier Units: The number of anesthesia modifier units will depend on the modifier being submitted.
For appropriate modifier units, refer to the Provider Portal in azblue.com and access
the Modifier Pricing Actions Table located under Claims Management Tab.
Time Units: Each 15 minute period represents 1 unit of service. Any additional time over the 15
minutes would add additional time units. Example:
15 minutes = 1 Time Unit

16 minutes = 2 Time Units
Maximum of 24 Maternity Epidural Anesthesia Time Units allowed per encounter (i.e. services from
the same provider for the same patient and date of service). Providers are required to bill the number of
maternity epidural anesthesia time units to accurately reflect the actual time the epidural was
administered.
NOTE: If multiple anesthesiologists are rendering services for the same patient and on the same
encounter, each can get reimbursed for the maximum 24 time units provided that they bill with
the appropriate fee reduction modifiers (e.g. QX, QK, etc.). For additional coding information
on multiple anesthesiologists billing on same encounter, refer to the Anesthesia Pricing
Guidelines Section G - Billing Criteria of Anesthesia Modifiers in azblue.com.
Maternity Epidural PGL-External Page 2 of 5

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An Independent Liceruee of the

Criteria: (cont.)
Pricing Example 1: (Anesthesia claim for maternity epidural -Anesthesia Time Units within Maximum):
Anesthesia Time: 12:00 - 6:00 (6 hours = 360 minutes. divided by 15 minutes = 24 Time Units)
Procedure Code: 01967 (5 Base Units)
Modifier: P3 (1 Additional Unit)

5 1 24 30
Pricing Example 2: {Anesthesia claim for maternity epidural -Anesthesia Time Units Over Maximum):
Anesthesia Time: 12:00 - 7:00 (7 hours= 420 minutes. divided by 15 minutes= 28 Time Units)
5 1 24(Not 28) 30
(Maximum Time)
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Criteria: (cont.)
Pricing Example 3: [Anesthesia claim submitted with TWO epidural codes (e.g. 01967 & 01968) -
Anesthesia Time Units Over Maximum]
NOTE: Maximum of 24 Time Units for entire claim.
Codes are as follows:
1•1 Code: 01967 - P3:

Anesthesia Time: 12:00 - 6:15 (6.25 hrs.= 375 min. divided by 15 min.= 25 Time Units)
Base Units: 5 Base Units
Modifier P3: 1 Modifier Unit
2nd Code: 01968 - P3:

Anesthesia Time: 6:15- 7:00 (45 mins. divided by 15 min.= 3 Time Units)
Base Units: 3 Base Units
Modifier P3: 1 Modifier Unit

01967: 5 1 24 (Not 25) 30
(Maximum Time)
01968: 3 0 (Max on 01967) 4
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Resources:
1. Blue Cross Blue Shield of Arizona Coding Guidelines
2. Current Procedural Terminology (CPT®), American Medical Association
Coding:
CPT: 01960, 01961, 01967, 01968
American Medical Association CPT Copyright Statement

CPT copyright American Medical Association (AMA). All rights reserved. CPT is a registered trademark of
the AMA. Applicable FARS/DFARS restrictions apply to government use. Fee schedules, relative value
units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT,
and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or
dispense medical services. The AMA assumes no liability for data contained or not contained herein.

...,:
T. . d of.Ariwna

Changes : Removed reference of moderate sedation codes (99151-99153 and 99155-99157) and Appendix G
from Description and Criteria sections, plus added clarification of billing time units on page 7 and
added asterisk to clarify "note" on page 5 in reference to billing with modifier QS.
ANESTHESIA SERVICES PRICING GUIDELINES
Coverage for services, procedures, medical devices and drugs are dependent upon benefit
eligibility as outlined in the member's specific benefit plan. This Pricing Guideline must be read in
its entirety to determine coverage eligibility, if any.
The section identified as " Description " defines or describes a service, procedure, medical device
or drug and is in no way intended as a statement of medical necessity and/or coverage.
The section identified as "Criteria" defines criteria to determine whether a service, procedure,
medical device or drug is considered medically necessary or experimental or investigational.
The section identified as "Pricing" defines criteria to determine how to price anesthesia services
using units (time, base and modifier units).
Pricing Guidelines are subject to change as new information becomes available .
Description:
Sedation and analgesia comprise a continuum of states ranging from minimal sedation through general
anesthesia. Sedation/anesthesia services include the usual pre-operative and postoperative visits, the
anesthesia care during the procedure, the administration of fluids and/or blood and the usual monitoring
services (e.g., ECG, temperature, blood pressure, oximetry, capnography and mass spectrometry).
CPT anesthesia service codes 00100 through 01999 (excluding 01953 and 01996) can be used to
describe minimal sedation, deep sedation, general anesthesia and monitored anesthesia care services.
Reporting of anesthesia services is appropriate when provided by or under the medical supervision of a
physician. The anesthesia codes should be used only by physicians not performing the surgical
procedures.
CPT codes 99151 - 99153 can be used to describe moderate sedation services administered by the
same provider performing the diagnostic or therapeutic service. CPT codes 99155 - 99157 can be used to
describe moderate sedation services administered by a different provider other than the provider
performing the diagnostic or therapeutic service.
As of 7/1/2018, BCBSAZ no longer recognizes the 2016 Current Procedural Terminology (CPT) Appendix
G, "Summary of CPT Codes That Include Moderate (Conscious) Sedation" nor any associated guidelines
for submitting these codes.
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Anesthe ia Pricing Guidelines - Externa l
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REVISION DATE: 6118/2018
Changes: Removed reference of moderate sedation codes (99151-99153 and 99155-99157) and Appendix G
ANESTHESIA SERVICES PRICING GUIDELINES (cont.)
Description: (cont.)
Deep Sedation/Analgesia:
A drug-induced depression of consciousness. Individual cannot be easily aroused but responds
purposefully following repeated or painful stimulation. Ability to independently maintain ventilatory function
may be impaired. May require assistance in maintaining a patent airway and spontaneous ventilation may
be inadequate. Cardiovascular function is usually maintained.
General Anesthesia:
A drug-induced loss of consciousness. Individual is not arousable, even by painful stimulation. The ability
to independently maintain ventilatory function is often impaired. Often requires assistance in maintaining a
patent airway and positive pressure ventilation may be required because of depressed spontaneous
ventilation or drug-induced depression of neuromuscular function. Cardiovascular function may be
impaired.
Minimal Sedation (Anxiolysis):

A drug-induced state. Individual responds normally to verbal commands. Although cognitive function and
coordination may be impaired, ventilatory and cardiovascular functions are unaffected. Examples include
local or topical anesthesia, regional anesthesia, (nerve blocks, spinal and epidural anesthesia), oral
sedative or analgesic medication. Local anesthesia numbs just a small area of tissue where a minor
procedure is to be done.
Moderate Sedation/Analgesia (Conscious Sedation):

A drug-induced depression of consciousness. Individual responds purposefully to verbal commands,
either alone or accompanied by light tactile stimulation. No interventions required to maintain a patent
airway and spontaneous ventilation is adequate. Cardiovascular function is usually maintained.
Monitored Anesthesia Care {MAC}:

Anesthesiologist is requested to be present during procedure in case the individual needs some type of
anesthesia. Individual may receive a local anesthesia, intravenous analgesia or no anesthesia at all. In all
cases, the anesthesiologist monitors vital signs and is available to administer anesthetics or to provide
other medical care as appropriate.
Qualifying Circumstances for Anesthesia:

Anesthesia services provided under difficult circumstances, such as extraordinary condition of individual,
notable operative conditions and/or unusual risk factors.
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Anesthesia Pricing Guidelines - External
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Criteria:
The following table (Criteria A) separates the different types of anesthesia and the procedure codes that
correlate. The table will chart the eligibility and reimbursement between a provider performing the surgical
procedure plus administering the anesthesia (same provider), compared to another provider administering
only the anesthesia (different provider).
A. DEEP SEDATION-GENERAL ANESTHESIA/ MINIMAL SEDATION / MONITORED ANESTHESIA

CARE:
Provider Dee(! Sedation / General Minimal Sedation

Anesthesia / Monitored
Anesthesia Care
[CPT: 00100--01999] ICPT: 64400-64530]
[CPT: 00100--01999] ICPT: 64400-64530]
Same provider performing the Not Eligible for reimbursement Not Eligible for reimbursement
surgical procedure and
administering anesthesia /
sedation (00100-01999 Considered an /64400 - 64530 Considered an
included service.) incidental service.)
[CPT: 00100--01999] [CPT: 64400-64530]
Different provider (other than Eligible for reimbursement. Not Eligible for reimbursement
the provider performing the
procedure) /64400 - 64530 Considered an
incidental service.)
B. Stand By Services:
Anesthesia stand by services are eligible for reimbursement with documentation of ALL of the
following:
1. Medically necessary percutaneous coronary angioplasty (PTCA)
2. Anesthesia provider is physically present
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Criteria: (cont.)
C. Services that are Included in Sedation or Anesthesia Services-FACILITY OR NON-FACILTY

Settings:
Refer to the Included Services Pricing Guideline for items that are considered included in office
visits. surgeries, sedation or anesthesia services.
The following services are an integral part of the sedation or the anesthesia and are considered
included when rendered in EITHER a FACILITY or NON-FACILITY setting and are not eligible for
separate reimbursement. These services should not be reported separately:
1. DME items or supplies that are integral to the administration of anesthesia and the
transportation of those items to the office or facility settings (e.g., nasopharyngeal airway,
backup power source, external defibrillator, wheeled cart)
2. Pre-operative and postoperative assessment of the individual receiving sedation or anesthesia
(not included in intra-service time')
3. Establishment of IV access and administration of fluids and/or blood products incident to the
procedure
4. Administration of the anesthetic or analgesic agent(s)
5. Maintenance of sedation
6. Interpretation and reporting of noninvasive monitoring during sedation (e.g., ECG/EKG,
temperature, blood pressure, oximetry, capnography, mass spectrometry, EEG and BIS EEG)
7. Field avoidance (i.e., anesthesiologist does not have direct access to the patient's airway
during surgery)
8. Position change (i.e., any procedure requiring a position other than supine or lithotomy)
• Intra-service time begins when medication is given to start the sedation and requires continuous
face-to-face attendance and ends when the physician is no longer in attendance.
D. Services that maybe Eligible for Separate Reimbursement in a NON FACILITY Setting ONLY:
The following services when rendered in a NON-FACILITY setting may be eligible for separate
reimbursement
1. General anesthetic supplies (e.g., IV tubing, supplies for external infusion pump)
2. DME items related to administration of oxygen (e.g., oxygen, liquid oxygen system rental,
regulator)
3. General anesthetic or analgesic agent(s)
Page 4
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An Lndepe n dent Li censee of Lhe
PRICING GUIDELINES EFFECTIVE DATE: 71112018

REVISION DATE: 611812018
Changes : Removed reference of moderate sedation codes (99151-99153 and 99155-99157) and Appendix G
from Description and Criter ia sections , plus added clarification of billing time units on page 7 and
added asterisk to clarify " note" on page 5 in reference to billing with modifier QS.

Criteria: (cont.)
E. Anesthesia Modifiers:
For anesthesia services to be eligible for separate reimbursemen,tone of the anesthesia modifiers
listed below (47, AA, AD, QK, QS , QX, OY and OZ) must be appended to the anesthesia procedure
code (00100 - 01999).
> Modifier 47: Anesthesia by surgeon.

NOTE: Modifier 47 is only eligible for separate reimbursement for provider specialties of
"oral surgery" and/or" oral & maxillofacial surgery" , otherwise anesthesia services
are considered included in the provider's reimbursement for the diagnostic or therapeutic
procedure.
> Modifier AA: (Anesthesiologistmodifier) Anesthesia services performed personally by
anesthesiologist.
>- Modifier AD: (Anesthesiologist modifier) Medical supervision by a physician: more than 4
concurrent anesthesia procedures.
>-- Modifier OK: (Anesthesiologist modifier) Medical direction of 2, 3 or 4 concurrent anesthesia
procedures involving qualified individuals.
:;... n Modifier OS: Moni t ored anesthesia care service.
(Anesthesiologist: If personally performed the anesthesia service to the patient and also
administered Monitored Anesthesia Care (MAC), the modifiers used would
be AA and QS.)
(CRNA: If CRNA is without medical directions by an anesthesiologist and bills with the
modifier QZ and personally performed the anesthesia service to the patient and also
administered Monitored Anesthesia Care (MAC), the modifiers used would be QZ
and QS.)
NOTE: For anesthesia services appended with a modifier QS to be eligible for separate
reimbursement, an additional anesthesia modifier (AA, AD, QK, OX, QY or QZ) is
required.
>- Modifier OX: (CRNA modifier) CRNA service; with medical direction by an anesthesiologist.
:.-- Modifier QY: (Anesthesiologist modifier) Medical direction of one certified registered nurse
anesthetist (CRNA) by an anesthesiologist.
, Modifier OZ: (CRNA modifier) CRNA service: without medical direction by an anesthesiologist.
NOTE: Possible Anesthesia Modifier Reimbursement Reduction

To verify if reimbursement reduction apply to any of the above listed anesthesia modifiers,
access the "Modifier Pricing Action" listing located in the secure provider portal at
azblue.com/providers in "Provider Resources > Claim Pricing > Modifier Pricing Action
Listing". If modifier not listed, no reduction applies.
Page 5
Anesthesia Pricin g Guidelines - External
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T. . :d
of Arizona
An Indepe ndent Lice nsee or the
Blue Cross and Blue Shield Assoc iation

Changes: Removed reference of moderate sedation codes (99151-99153and 99155-99157) and Appendix G
from Description and Crit eria sections , plus added clarificatio n of billing time units on page 7 and
Criteria: (cont.)
F. Billing Criteria of Anesthesia Modifiers :

The following criterion explains how Anesthesiologists and CRNAs (certified registered nurse
anesthetist) should bill BCBSAZ for services:
Anesthesiologist working independently:

, Submit the claim under the Anesthesiologist's NPI number
Include modifier AA
CRNA that is medically directed by an Anesthesiologist:

> Separate claims should be submitted by each practitioner (CRNA and anesthesiologist) using
his/her own NPI number and the appropriate modifier(s)
> B oth Anesthesiologist and CRNA should submit the same CPT code(s) and time on both their
separate claims.
> Fo llowing modifiers should be noted on the claim for either Anesthesiologist or CRNA:
• Modifiers for Anesthesiologist when directing/supervising CRNA(s):
./ AA and QY in conjunction: If medically directing one CRNA
./ AA and QK in conjunction: If medically directing two - four concurrent anesthesia
procedures
./ AA and AD in conjunction: If supervising more than four anesthesia procedures
• Modifier for CRNA being directed by anesthesiologist : QX
• Modifier for CRNA that work independently (without anesthesiologist): QZ
NOTE: To verify if reimbursement reduction apply to any of the above listed anesthesia
modifiers , access theu Modifier P ricing Action" listing located in the secure provider
portal at azblue.com/prov1ders in "Provider Resources > Claim Pricing > Modifier Pricing
Action Listing". If modifier not listed, no reduction applies.
Page 6
Anes thes ia Pric ing Guid elin es - External
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ofAriwna
An Independent licensee or the

Pricing:
The following anesthesia pricing methodology will be used to reimburse a claim for anesthesia
services (00100-01999 , except for 01953 and 01996. Refer to note below):
Determining Anesthesia Units:
Reimbursement methodology reflects:
Base Units+ Modifier Units+ Time Units= Total Units
Base Units: The number of anesthesia base units will depend on the CPT Code being submitted.
For appropriate base units, logon to the secure provider portal at
azblue.com/oroviderand access the Anesthesia Base Units document using the
following path: "ProviderResources> Claim Pricing > Anesthesia Base Units"
Modifier Units: The number of anesthesia modifier units will depend on the modifier being
submitted. For appropriatemodifier units, logon to the secure provider portal at
azblue.com/oroviderand access the Modifier Pricing Actions Table document
using the following path: "Provider Resources > Claim Pricing > Modifier Pricing
Actions Lists"
Time Units: Each 15 minute period represents 1 unit of service. Any additional time over the 15
minutes would add additional time units. Example:
15 minutes = 1 Time Unit
(Providers required to bill the number of anesthesia units to accurately

reflect the actual time the anesthesia was administered to patient face-to-
face.)
NOTE: For maternity epidural anesthesia, the maximum anesthesia time units is 24 Time Units
per encounter (i.e., services from the same pro vider for the same patient and date of
service). Providers are required to bill the number of maternity epidural anesthesia time
units to accurately reflect the actual time the epidural was administered.
(For matern ity epidural anesthesia pricing examples, refe r to Maternity Epidural
Anesthesia Pricing Guideline located in azblue.com/orovider.)
NOTE: Per ASA-RVG®, CPT 01953 and 01996 should not be submitted as time-base services and thus
are not considered anesthesia services and will not reimburseper the above anesthesia pricing
formula (which is based on time units). CPT 01953 and 01996 will reimburse using the Fee
Schedule multiplied by the number of service units reported.
Page 7
Anesthesia Pricing Guid elines - Exte rnal
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Pricing: (cont.)
Pricing Example 1: (Anesthesia Time divisible by 15 minutes)
Anesthesia Time: 12:00 - 6:00 (6 hours= 360 minutes divided by 15 minutes = 24 Time Units)

5 1 24 30
Pricing Example 2: (Anesthesia Time not divisible by 15 minutes)
Anesthesia Time: 12:00 -6:05 (6 hours & 5 minutes= 365 minutes divided by 15 minutes= 24.33
Time Units = 25 Time Units)

5 1 25 31
Coding Referenced:
CPT: 00100 - 01999, 64400 - 64530, 95999, 99100, 99116, 99135, 99140, 99151, 99152, 99153,
99155,99156, 99157, 99360
Appendix G
HCPCS: G0104, G0105, G0106, G0120, G0121, G0297
Anesthesia Modifiers: 47, AA, AD, QK, QS, QX, QY, QZ
Resources:
1. American Medical Association. Current Procedural Terminology (CPT®)
2. Health Care Procedure Coding System (HCPCS®)
3. Centers for Medicare & Medicaid Services (CMS®)
American Medical Association CPT Copyright Statement

CPT Copyright American Medical Association (AMA). All rights reserved. CPT is a registered trademark of
the AMA. Applicable FARS/DFARS restrictions apply to government use. Fee schedules, relative value
units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT,
and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or
dispense medical services. The AMA assumes no liability for data contained or not contained herein.
Page 8

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BLUE CROSS AND BLUE SHIELD OF ARIZONA

PROFESSIONAL SERVICES PARTICIPATION AGREEMENT

Specialty: Anesthesiology (MD/DOs)

[g] Indemnity [g] PPO [g] HMO

• As of the effective date of this Agreement: $72.00 per ASA unit.

[g] Medicare Supplement - Senior Preferred

As of the effective date of this Agreement , for Covered Services rendered to

[&] Workers' Compensation

As of the effective date of this Agreement, for services rendered to employees

D Alliance network D Acclaim network D Select network

As of the effective date of this Agreement, for Covered Services rendered to

Revised 3-10-15, Printed 5/15/15, PROFESSIONAL AGRMT 3-10-15 LTA GAP.DOC

Provider acknowledges the following:

(The remainder of this page intentionally left blank)

Revised 3-10-15, Printed 5115/15, PROFESSIONAL AGRMT 3·10-15 LTR GAP.DOC

PRICING GUIDELINES EFFECTIVE DATE: 12/1/2009

MATERNITY EPIDURAL ANESTHESIA

Pricing Guidelines are subject to change as new information becomes available.

)- Reimbursement methodology reflects:

Base Units + Modifier Units + Time Units = Total Units

Maternity Epidural PGL·External Page 1 of 5

PRICING GUIDELINES EFFECTIVE DATE: 12/1/2009

MATERNITY EPIDURAL ANESTHESIA (cont.)

15 minutes = 1 Time Unit

Maternity Epidural PGL-External Page 2 of 5

PRICING GUIDELINES EFFECTIVE DATE: 12/1/2009

MATERNITY EPIDURAL ANESTHESIA (cont.)

Base Units + Modifier Units + Time Units = Total Units

PRICING GUIDELINES EFFECTIVE DATE: 12/1/2009

MATERNITY EPIDURAL ANESTHESIA (cont.)

Codes are as follows:

1•1 Code: 01967 - P3:

2nd Code: 01968 - P3:

Base Units + Modifier Units + Time Units = Total Units

Maternity Epidural PGL-Extemal Page 4 of 5

PRICING GUIDELINES EFFECTIVE DATE: 12/1/2009

MATERNITY EPIDURAL ANESTHESIA (cont.)

1. Blue Cross Blue Shield of Arizona Coding Guidelines

2. Current Procedural Terminology (CPT®), American Medical Association

CPT: 01960, 01961, 01967, 01968

American Medical Association CPT Copyright Statement

Maternity Epidural PGL-External Page 5 of 5

PRICING GUIDELINES EFFECTIVE DATE: 7/1/2018

ANESTHESIA SERVICES PRICING GUIDELINES

Pricing Guidelines are subject to change as new information becomes available .

PRICING GUIDELINES EFFECTIVE DATE: 7/1/2018

ANESTHESIA SERVICES PRICING GUIDELINES (cont.)

Minimal Sedation (Anxiolysis):

Moderate Sedation/Analgesia (Conscious Sedation):

Monitored Anesthesia Care {MAC}:

Qualifying Circumstances for Anesthesia:

PRICING GUIDELINES EFFECTIVE DATE: 7/1/2018

ANESTHESIA SERVICES PRICING GUIDELINES (cont.)

A. DEEP SEDATION-GENERAL ANESTHESIA/ MINIMAL SEDATION / MONITORED ANESTHESIA

Provider Dee(! Sedation / General Minimal Sedation

[CPT: 00100--01999] ICPT: 64400-64530]

[CPT: 00100--01999] ICPT: 64400-64530]

[CPT: 00100--01999] [CPT: 64400-64530]

PRICING GUIDELINES EFFECTIVE DATE: 7/1/2018

ANESTHESIA SERVICES PRICING GUIDELINES (cont.)

C. Services that are Included in Sedation or Anesthesia Services-FACILITY OR NON-FACILTY

PRICING GUIDELINES EFFECTIVE DATE: 71112018

ANESTHESIA SERVICES PRICING GUIDELINES (cont.)