TRICARE Anesthesia Billing and Reimbursement

Providers are reminded that payments for TRICARE anesthesia claims follow the TRICARE reimbursement policies, not the American Society of Anesthesiologists (ASA) "Relative Value Guide."

Coding

Providers should bill with the anesthesia CPT codes (00100-01999) and not the surgical CPT codes. The appropriate CPT anesthesia code should be reflected on the CMS 1500. 

Conversion Factors

Payment is calculated by multiplying the applicable conversion factor by the appropriate number of base units plus time units for each code. There are two conversion factors – one for physicians and one for non-physicians.

Wage Indices

The conversion factors are adjusted by wage indices for each locality. The locality-specific conversion factors are adjusted in the same manner as the CHAMPUS maximum allowable charges (CMACs). The current conversion factors are compared to the Medicare locality-specific conversion factors.

Time Units/Modifiers

Base units for each procedure are derived from the Medicare Anesthesia Relative Value Guide. Time units are 15 minutes, and any fraction of a unit is considered a whole unit. Time units will be submitted on the claim. 

Providers should also show a payment indicator (not a modifier) of 'MJ' if the number they're showing on the claim form represents minutes and 'UN' if it represents 15-minute units. TRICARE reimbursement of anesthesia services is calculated using the number of time units, the Medicare relative value units and the anesthesia conversion factor.

If the payment indicators aren’t shown, TriWest does not know whether providers are indicating the number of minutes the patient was under anesthesia or whether it is the number of 15-minute increments. This could result in a delay in claims reimbursement or incorrect payment.

If appropriate, providers should also include a physical status modifier, e.g., if the patient has multiple health issues to allow additional reimbursement as it was not a "simple" case.

Payment Level

Since payment rates distinguish between physicians and non-physicians, each anesthesia claim must identify who provided the anesthesia. In those cases where part of the anesthesia service is provided by an anesthesiologist and the remainder by a non-physician anesthetist, the claim(s) must identify the exact services provided by each type of provider, so that the appropriate reimbursement rate can be applied.

Administration of general anesthesia by the operating surgeon is not covered. If the surgeon bills a single charge which includes both the surgery and the anesthesia, a breakdown of the charge will need to be provided with billing or the anesthesia services will be denied. When a breakdown of charges is not available, payment will be based on the allowable charge for the surgery alone.

Generally the total amount allowed for anesthesia provided by an anesthesiologist and a non-physician anesthetist cannot exceed what would have been allowed had the anesthesia been provided only by an anesthesiologist. In no case can it exceed that amount if the non-physician anesthetist is an anesthesiologist assistant. If the non-physician anesthetist is a certified registered nurse anesthetist, the total allowed amount can exceed that amount only if unusual circumstances warrant additional payment and those circumstances are documented in the medical record.

For further information, please refer to TRICARE Reimbursement Manual, Chapter 1, Section 9.