🩺 1.

General Anesthesia

 Definition: Complete loss of consciousness. Patient does not

respond to pain or stimuli.

 Method: Usually delivered via inhalation or IV.

 Used for: Major surgeries (e.g., heart surgery, abdominal

surgery).

 CPT Range: 00100–01999

🩺 2. Regional Anesthesia

 Definition: Numbs a larger region of the body.

 Patient stays awake, but has no feeling in the area.

 Types:

o Spinal anesthesia (e.g., for C-section)

o Epidural anesthesia (e.g., during labor)

o Nerve blocks (e.g., for shoulder or knee surgery)

🩺 3. Local Anesthesia

 Definition: Numbs a very small, specific area.

 Used for: Minor procedures (e.g., skin biopsy, dental

procedures).

 Administered: As an injection or topical cream.

🩺 4. Monitored Anesthesia Care (MAC)

 Definition: Sedation with continuous monitoring by an

anesthesiologist.

 Patient is sedated but can respond.

 Often used with local anesthesia.

 Codes: Use anesthesia CPT codes (00100–01999)

✅ Analogy: Like putting your phone in silent mode but keeping an

eye on it — sedation is mild, but you're closely watched.
🩺 5. Conscious (Moderate) Sedation

 Definition: Depresses consciousness enough for a

procedure, but patient can still respond to commands.

 Codes: 99151–99157

✅ Analogy: Like a light nap — you’re drowsy but still responsive if

someone calls your name.

Quick Comparison Table:

Type Consciou Scope of Common Use Code

s? Numbness Range

General No Whole Major surgeries 00100–

Anesthesia body 01999

Regional Yes Body C-section, 00100–

Anesthesia region orthopedic 01999 +
(e.g., leg) surgery Mod.

Local Yes Small area Biopsies, Usually

Anesthesia dental bundled
procedures

Monitored Yes May Colonoscopy, 00100–

Anesthesia combine cataract 01999
Care with local surgery

Conscious Yes None Minor 99151–

Sedation (sedation procedures 99157
only) with mild
sedation

🔹 What Are Base Units?

Base Units are fixed values assigned by CMS (Centers for

Medicare & Medicaid Services) to each anesthesia CPT code
(00100–01999).
They reflect:

 The complexity of the procedure,

 Skill and risk involved,

  Patient positioning, and

 Usual monitoring services.

👉 You can find base units in the Medicare Anesthesia Base Unit
Schedule.

🔹 What Are Time Units?

Time Units are calculated based on how long the anesthesiologist

was personally attending the patient.

Rule:
For Medicare, 1 time unit = 15 minutes of anesthesia time.

 So, 30 minutes = 2 time units

 45 minutes = 3 time units

 60 minutes = 4 time units

(Always round to the nearest tenth if required by payer
policy)

🔹 Formula to Calculate Anesthesia Reimbursement

pgsql

CopyEdit

Total Units = Base Units + Time Units (+ Modifying Units, if

applicable)

Total Payment = Total Units × Conversion Factor (e.g., $20–$25)

🏥 Example:

A patient undergoes a knee arthroscopy (CPT 01400)

 Base Units for 01400 = 4

 Anesthesia time = 1 hour = 4 time units

 Conversion Factor (say Medicare uses) = $22

🔢 Total Units = 4 (Base) + 4 (Time) = 8

💰 Total Payment = 8 × $22 = $176
Anesthesia Guidelines

Services involving administration of anesthesia are reported by the use of

the anesthesia five-digit procedure code (00100–01999) plus modifier
codes (defined under “Anesthesia Modifiers” later in these Guidelines).

The reporting of anesthesia services is appropriate by or under the

responsible supervision of a physician. These services may include but are
not limited to general, regional, supplementation of local anesthesia, or
other supportive services in order to afford the patient the anesthesia care
deemed optimal by the anesthesiologist during any procedure. These
services include the

usual preoperative 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).

Unusual forms of monitoring (e.g., intra-arterial, central venous, and

Swan-Ganz) are not included.

Items used by all physicians in reporting their services are presented in

the Introduction. Some of the commonalities are repeated in this section
for the convenience of those physicians referring to this section on
Anesthesia. Other definitions and items unique to anesthesia are also
listed.

 To report moderate (conscious) sedation provided by a physician

also performing the service for which conscious sedation is being
provided, see codes 99151, 99152, 99153.

 When a second physician (not the health care professional

performing the diagnostic or therapeutic services) provides
moderate (conscious) sedation in the facility setting (e.g., hospital,
outpatient hospital/ambulatory surgery center, skilled nursing
facility), the second physician reports the associated moderate
sedation procedure/service 99155, 99156, 99157.
  When these services are performed by the second physician in the
nonfacility setting (e.g., physician office, freestanding imaging
center), codes 99155, 99156, 99157 would not be reported.

 Moderate sedation does not include minimal sedation (anxiolysis),

deep sedation, or monitored anesthesia care (00100–01999).

 To report regional or general anesthesia provided by a physician also

performing the services for which the anesthesia is being provided,
see modifier 47 in Appendix A.

Time Reporting

 Time for anesthesia procedures may be reported as is customary in

the local area.

 Anesthesia time begins when the anesthesiologist begins to

prepare the patient for induction of anesthesia and ends when
the anesthesiologist is no longer personally attending the
patient (when they can be safely placed under postoperative
supervision).

📖 Guidelines:

Time for anesthesia procedures is reported based on local customary

practices.

Anesthesia time starts ➔ when the anesthesiologist begins preparing the

patient for induction (even before surgery actually starts).

Anesthesia time ends ➔ when the anesthesiologist is no longer personally

attending the patient (i.e., the patient is stable and safely handed over for
recovery).

🏥 Example:

8:00 AM: The anesthesiologist begins preparing the patient in the pre-op
area (starting IV lines, giving sedation).

8:30 AM: Anesthesia induction happens, surgery starts.

10:00 AM: Surgery ends, patient moved to recovery (PACU).

10:10 AM: Anesthesiologist personally monitors the patient until fully

stable.

10:20 AM: Patient safely under postoperative nurse supervision,

anesthesiologist leaves.
✅ Anesthesia time reported = From 8:00 AM to 10:20 AM (2 hours and 20
minutes)

👉 Not just the surgery time, but the total time the anesthesiologist was
involved, including pre-surgery preparation and immediate post-op
stabilization.

Anesthesia Services

 Services rendered in the office, home, or hospital consultation are

listed in the Evaluation and Management Services section (98000–
98016, 99202–99499 series).

 "Special Services, Procedures and Reports" (99000–99082 series)

are listed in the Medicine section.

📖 Guidelines:

1. Office, Home, or Hospital Consultation services are listed in

the Evaluation and Management (E/M) Services section (codes
98000–98016, 99202–99499).

2. Special Services, Procedures and Reports are listed in the

Medicine section (codes 99000–99082).

🏥 Example 1: (Office, Home, Hospital Consultation — E/M Services)

A patient visits the hospital for a consultation about unusual chest pain.

👉 The doctor performs:

 A detailed history

 A detailed examination

 Moderate decision making

👉 The doctor chooses E/M code 99223 (Initial hospital care).

✅ This code (99223) comes from the 99202–99499 E/M series

mentioned in the guideline.

🏥 Example 2: (Special Services — Medicine Section)

A clinic collects a blood sample from the patient to send to an external

lab.
👉 The act of handling and processing the specimen (but not the lab
test itself) can be reported with code 99000:

 99000 = Handling and/or conveyance of specimen for transfer to a

laboratory.

✅ This code (99000) comes from the 99000–99082 Medicine section

for Special Services, Procedures, and Reports.

Supplied Materials

 Supplies and materials (e.g., sterile trays, drugs) over and above
the usual office visit or other services can be reported separately
using 99070 or an appropriate supply code.

🏥 Example:

A patient comes to the clinic for a minor wound suturing (stitches).

Normally, the clinic visit fee already includes:

 Gloves

 Basic sterile gauze

 Local anesthesia (like lidocaine)

But in this case, the doctor also uses:

 A specialized wound dressing kit (not routinely used)

 Tetanus vaccine given after stitching (an extra drug)

Since these items are over and above what is normally included in
wound suturing, 👉 the doctor can bill separately for:

 The special dressing kit using 99070 (supplies code)

 The tetanus vaccine using the appropriate vaccine drug code.

✅ Result:
You can charge extra for these additional supplies besides the
procedure code.

Separate or Multiple Procedures

  If multiple surgical procedures are performed during a single
anesthesia administration, the most complex procedure is
reported, and the time is combined for all procedures.

🏥 Example:

A patient goes for surgery and during one anesthesia session:

 The surgeon removes the gallbladder (cholecystectomy — CPT

47562)

 And repairs an umbilical hernia (hernia repair — CPT 49585)

The anesthesiologist administers one continuous anesthesia from start

to finish.

👉 What to code for anesthesia?

 Look at which surgical procedure is more complex (requires more

work, risk, and time).

o Gallbladder removal (cholecystectomy) is more complex

than hernia repair.

 So, you choose the anesthesia CPT code for cholecystectomy

(not both).

 Add the total anesthesia time spent for both procedures

together.

✅ Result:
One anesthesia CPT code (for gallbladder removal) + combined
anesthesia time for both surgeries.

Unlisted Service or Procedure

 If an anesthesia service is not listed in the CPT codebook, you can

use the Unlisted Procedure code 01999 and submit a Special
Report.

📖 Guideline Summary:

1. If the same physician performs both the procedure and

moderate sedation, use:
➤ 99151–99153
 2. If a second physician (not the one doing the main procedure)
gives sedation in a facility setting, use:
➤ 99155–99157

3. In a non-facility setting (e.g., private clinic), do not use 99155–

99157 for the second physician.

4. Moderate sedation ≠

o Minimal sedation (anxiolysis)

o Deep sedation

o Monitored anesthesia care (MAC → 00100–01999 codes)

🏥 Example 1: Same Physician (Use 99151–99153)

Dr. Smith performs a colonoscopy and also administers moderate

sedation himself in the clinic.

✅ Code the colonoscopy CPT + 99152 (for moderate sedation by same

physician for a procedure lasting 16–30 minutes on patient >5 years old)

🏥 Example 2: Second Physician in Facility (Use 99155–99157)

Dr. Lee performs a bone marrow biopsy in a hospital.

An anesthesiologist gives moderate sedation to the patient.

✅ Anesthesiologist reports 99156 (for 16–30 minutes)

❌ Dr. Lee should not report sedation — he only did the procedure.

🏥 Example 3: Second Physician in Nonfacility Setting (DO NOT use

99155–99157)

Same situation as above, but it's done in Dr. Lee’s private clinic.

❌ The anesthesiologist cannot report 99156 — because second-

physician sedation is not separately billable in nonfacility settings.

🎯 Simple Analogy:

Think of moderate sedation like giving calm sleep music and a

blanket during a medical “flight” 🛫.

 If the pilot (doctor doing procedure) also provides music and

blanket ➤ 99151–99153
  If a flight attendant (another physician) does it in an airport
(facility) ➤ 99155–99157

 But if you're on a private flight (nonfacility), the attendant can’t

bill you separately.

And if the passenger needs deep sleep (general anesthesia), that’s

another level — not included here (use 00100–01999).

1. To Communicate Patient Risk

 These modifiers inform payers and clinical staff about the

patient’s health status before anesthesia.

 A higher-risk patient (like P4 or P5) needs more careful

monitoring, more time, and potentially higher-skilled care.

2. To Justify Increased Resource Use

 Sicker patients may require:

o Longer anesthesia time

o More monitoring (e.g., invasive lines)

o Special drugs or support systems

👉 Using a modifier like P4 or P5 helps justify why the anesthesiologist

spent more time or effort, which can lead to higher reimbursement
with some private payers.

3. For Reimbursement Purposes (Private Payers)

 Medicare does not pay extra based on physical status modifiers.

 But many commercial insurance companies do.

o For example: They may pay an additional unit for P3, P4,
or higher, depending on their policy.

4. For Legal and Documentation Accuracy

 In case of audits or medical reviews, the modifier shows:

o Why the anesthesia case was more complex

 o Why certain procedures or monitoring were done

Modifi Description Example

er

P1 A normal healthy A 22-year-old healthy individual

patient undergoing elective wisdom
tooth extraction under general
anesthesia.

P2 A patient with mild A 45-year-old with well-

systemic disease controlled hypertension coming
for knee arthroscopy.

P3 A patient with severe A 60-year-old with poorly

systemic disease controlled diabetes and COPD
scheduled for hernia repair.

P4 A patient with severe A 70-year-old with unstable

systemic disease that is a angina and chronic heart
constant threat to life failure undergoing hip surgery.

P5 A moribund patient who A trauma patient with ruptured

is not expected to abdominal aneurysm, in shock,
survive without the needs emergency surgery.
operation

P6 A declared brain-dead A 30-year-old brain-dead patient

patient, organs being being prepped for kidney and
removed for donation liver harvesting.

✅ What are Qualifying Circumstances?

Qualifying Circumstances are add-on CPT codes (99100–99140)
used with anesthesia codes (00100–01999) to describe special risk
factors that make the anesthesia service more complex or dangerous.

They do not stand alone — they are used in addition to the primary
anesthesia code to justify the extra risk or effort involved.

📊 Qualifying Circumstance CPT Codes:

Code Description

9910 Anesthesia for patients of extreme age (under 1 year or over

0 70 years old)

9911
Anesthesia complicated by controlled hypotension
6

9913 Anesthesia complicated by hypothermia (temperature

5 deliberately lowered)

9914
Anesthesia complicated by emergency conditions
0

🏥 Examples:

1. 99100 – Extreme Age

A 6-month-old baby undergoes hernia repair under general anesthesia.

👉 Report 99100 + primary anesthesia code (e.g., 00830).

2. 99140 – Emergency

A trauma patient with internal bleeding is rushed into emergency surgery.

👉 Add 99140 to show the urgent nature of the anesthesia care.

3. 99116 – Hypothermia

During open-heart surgery, the patient's body temperature is lowered

intentionally to protect organs.
👉 Report 99116 in addition to the cardiac anesthesia code.

✅ CPT 99135 – Definition

"Anesthesia complicated by utilization of hypothermia"

🔍 What Does It Mean?

Hypothermia, in this context, is intentionally induced (not accidental).

It’s used in complex surgeries to:

 Protect vital organs, especially the brain and heart

 Reduce metabolic demand of tissues

 Improve outcomes in prolonged procedures

This requires advanced anesthesia management, close monitoring,

and high-risk oversight.

🏥 When to Use 99135:

 The anesthesiologist deliberately lowers the body

temperature (usually below 35°C or 95°F).

 Must be used in addition to the primary anesthesia CPT code

(00100–01999).

 Must be clearly documented in the anesthesia record.

🏥 Example:

A patient undergoes open-heart surgery involving cardiopulmonary

bypass.
To protect the brain during aortic arch repair, the anesthesiologist
induces hypothermia.

➡️Report:

 Primary anesthesia code for cardiac procedure (e.g., 00567)

 + 99135 (hypothermia as a qualifying circumstance)

🧠 CPC Exam Tip:

 These codes must be paired with a primary anesthesia code.

 They do not affect time units or base units, but they may
support higher reimbursement.
CPT Who Patien Time Settin Notes
Code Performs t Age Covered g
Sedation

9915 Same <5 Initial 15 Any Includes

1 physician years mins setting intraservice time
doing the and monitoring
procedure

9915 Same ≥5 Initial 15 Any Most commonly

2 physician years mins setting used in office,
doing the ASC, hospital
procedure

9915 Same Any Each Any Use only if total

3 physician age additional setting time exceeds 30
doing the 15 mins minutes
procedure

9915 Second ≥5 Initial 15 Facility Only used when

5 physician (not years mins only a different
doing provider gives
procedure) sedation

9915 Second ≥5 Each Facility Use only if

6 physician (not years additional only sedation >30
doing 15 mins mins; must
procedure) monitor full time

9915 Second <5 Each Facility Less common;

7 physician (not years additional only applies in
doing 15 mins pediatric
 procedure) sedation settings

Modifi Description Who Applies It Example

er

AA Anesthesia services Anesthesiologist Dr. Smith, an

personally only anesthesiologist,
performed by an performs the entire
anesthesiologist case himself → AA

AD Medical supervision Anesthesiologist Dr. John oversees 6

by a physician of supervising >4 CRNAs at the same
more than 4 cases time → AD
concurrent
procedures

QK Medical direction of Anesthesiologist Dr. Emily directs 3

2–4 concurrent supervising 2–4 CRNAs during
procedures by cases separate surgeries →
anesthesiologist QK

QX CRNA service with CRNA CRNA Jones is

medical direction medically directed
by physician by Dr. Emily → QX
QY Anesthesiologist Anesthesiologist Dr. Alan directs only
medically directs 1 one CRNA for a case
CRNA → QY

QZ CRNA service CRNA CRNA Sam works

without medical independently with
direction no anesthesiologist
→ QZ

🏥 Scenario: One CRNA with Medical Direction

👩‍⚕️Providers Involved:

 Dr. Anand, a board-certified anesthesiologist

 CRNA Priya, a certified registered nurse anesthetist

🛌 Patient:

 Undergoing open inguinal hernia repair (CPT code 00830)

🕒 Procedure Timeline:

 Case duration: 1 hour

 Dr. Anand medically directs CRNA Priya throughout:

o Reviews patient history and plan pre-op

o Checks in during induction

o Monitors the case intermittently

o Reviews post-op care and records

🧾 Billing Structure:

CPT Modifi
Provider Explanation
Code er

CRNA CRNA performed the anesthesia under

00830 QX
Priya medical direction

Dr. 00830 QY He medically directed exactly 1 CRNA —

 CPT Modifi
Provider Explanation
Code er

Anand qualifies for QY

🧠 QY is only valid when the physician directs one CRNA

👉 If he directed more than one, he’d use QK, not QY.

❗ Common Errors to Avoid:

Mistake Why It's Wrong

Billing QY while supervising 2

QY is only for 1 CRNA — should be QK
CRNAs

CRNA billing QZ in a directed QZ = no medical direction — wrong if

case supervised

Missing documentation for

May lead to denials or downcoding
supervision

🔁 Summary Table:

Modifi Direction Case Count

Used By Example Scenario
er Level Allowed

With medical CRNA supervised by

QX CRNA 1 or more
direction anesthesiologist

Anesthesiolog Directs 1 Physician directs 1

QY 1
ist CRNA only CRNA

Anesthesiolog Directs 2–4 Physician directs 3

QK 2–4
ist cases CRNAs

Would you like a billing cheat sheet PDF showing all anesthesia
modifiers (AA, QK, QX, QY, QZ, AD) with usage rules and CPT examples? 📄
✅

++++++++++++++++++++++++++++++++++++++++++++
++++++++++++++++++++++++++++++++++++++++++++
++++++++++++++++++++++++++++++++++++++++++++
++++++++

What is Medical Direction in Anesthesia?

Medical direction occurs when a physician (anesthesiologist)

supervises 1 or more CRNAs or AA (Anesthesiologist Assistants)
during anesthesia cases and meets specific CMS conditions.

It’s not the same as personally performing the anesthesia (that’s

modifier AA).
It’s also not general supervision (modifier AD).
This is an active role with defined responsibilities.

# Requirement

1 Perform a pre-anesthetic exam and evaluation

️
⃣

2 Prescribe the anesthesia plan

️
⃣

3 Personally participate in the most demanding procedures of the

️ case (e.g., induction/emergence)
⃣

4 Ensure that only qualified personnel are administering anesthesia

️
⃣

5 Monitor the course of anesthesia at frequent intervals

️
⃣

6 Be physically present and available for emergencies

️
⃣

7 Perform a post-anesthesia care visit

️
⃣

⚠️Missing any one of these steps = no medical direction → claim

should be downgraded to medical supervision (AD) with lower
reimbursement.
🏥 Examples of Medical Direction

📌 Scenario 1: One CRNA (QY/QX)

 Dr. Meena medically directs CRNA Priya during a knee surgery.

 She completes all 7 steps and monitors the case.

Billing:

 Dr. Meena: CPT + QY (1 CRNA, all steps met)

 CRNA Priya: CPT + QX

📌 Scenario 2: 3 CRNAs (QK/QX)

 Dr. Raj directs 3 CRNAs at once.

 He rotates between rooms, and documentation shows he performed

all 7 required tasks for each case.

Billing:

 Dr. Raj: CPT + QK (2–4 concurrent cases)

 Each CRNA: CPT + QX

📌 Scenario 3: Dr. John directs 5 CRNAs

➡️Fails CMS rule: More than 4 concurrent cases.

Billing:

 Dr. John: CPT + AD (medical supervision only) → much lower

payment

 CRNAs: CPT + QX

⚖️Why This Matters for Reimbursement:

Modifier(s) Physician
Situation
Used Reimbursement

Personally performed AA 💰 Full payment

Medical direction (1 CRNA) QY/QX 💰 Shared (each 50%)

Medical direction (2–4 cases) QK/QX 💰 Shared (each 50%)

 Modifier(s) Physician
Situation
Used Reimbursement

Supervision (>4 cases or missed

AD/QX 💸 Reduced significantly
step)

Type Definition Physician Where It

Presence Applies
Required?

General Services are furnished ❌ Not Diagnostic

Supervisio under the physician’s required tests, lab
n overall direction, but the during the tests, some
physician doesn’t have service telehealth
to be present.

Direct Physician must be ✅ Must be in “Incident-to”

Supervisio physically present in the facility services,
n the office suite and diagnostic
immediately available, tests in office
but not necessarily in the
room.

Personal Physician must be in the ✅ Must be in- Certain

Supervisio room during the entire room radiology,
n procedure. complex
diagnostic
tests