Time units, medical direction modifiers, postoperative block claims and payer follow-up, built on Medicare rules and your own contracts, with pre-case checks and a claims portal.
Quick answer
Anesthesia billing services turn each anesthesia record into a payable claim: base units plus time units, the right pricing modifier for who performed or directed the case (AA, QY, QK, QX, QZ or AD), postoperative blocks billed only when allowed, and payer follow-up. RCM Finder adds pre-case coverage checks, facility-facing marketing and a claims portal.
Anesthesia is paid on units and minutes, not a fixed fee per code. Each claim carries base units, minutes of anesthesia time and a modifier that says who performed or directed the case. One wrong modifier can halve a payment.
Under 42 CFR 414.46, Medicare pays base units plus time units, multiplied by an anesthesia conversion factor. Base units cover work other than time, such as usual pre- and post-operative visits. One time unit is 15 minutes, and no extra modifier units are allowed. Several procedures in one session use the highest base unit and the total time. CMS's billing instructions sit in section 50 of chapter 12 of its claims manual. For a primer, read our anesthesia billing guide.
CMS posted its 2026 conversion factor files on its Anesthesiologists Center page in December 2025; base units did not change. The American Society of Anesthesiologists' summary of the CY 2026 final rule (October 31, 2025) lists a national factor of $20.4976 for most clinicians and $20.5998 for qualifying APM participants, up from $20.3178 in 2025. Contractors adjust it by locality: Noridian's 2026 table lists $20.21 per unit for participating clinicians in Arizona and $21.74 in Seattle (King County).
An illustrative case: 5 base units and 72 minutes. 72 ÷ 15 = 4.8 time units, so 9.8 units in all. At Arizona's 2026 rate, the allowed amount is 9.8 × $20.21 = $198.06 if an anesthesiologist personally performs it. If the case is medically directed, the anesthesiologist and the CRNA are each allowed 50%, or $99.03.
Anesthesia time runs from when the practitioner starts preparing the patient until the patient can safely go to postoperative care. Claims carry actual minutes; Noridian turns 321 minutes into 21.4 time units. A break comes off the total, but continuous blocks on either side still count. The 2026 NCCI policy manual excludes recovery time. When two anesthesiologists share a case, Noridian expects one claim with all time combined.
An anesthesia group needs facilities and surgeons who trust it, complete case data, claims coded to the minute and the modifier, and software that shows where every case sits.
Revenue leaks at the handoffs: a face sheet with the wrong plan, a record without a stop time, a block billed when it was the anesthetic. We run all four pillars on one set of rules.
Anesthesia cases come from facilities and surgeons, not patient ads. Our healthcare digital marketing builds what facility leaders, surgeons and job candidates check: coverage pages, partner pages, recruiting pages and reputation work.
Our virtual medical assistants for anesthesia groups work on your practice's time zone. Before cases, they check coverage, the surgery's authorization and network status. After cases, they chase missing records and answer patient billing calls.
Our end-to-end anesthesia revenue cycle management covers charge entry, coding support, claim scrubbing, payment posting, denials and A/R follow-up, with extra checks on minutes, ratios, modifiers and block claims.
Our practice management system tracks every case by claim stage, applies specialty-aware billing logic per claim, checks data completeness before submission and flags underpayments. Billing companies serving several groups get a client portal.
Find where your anesthesia claims leak
We review recent cases, remittances and denials, then show where minutes, modifiers or block claims cost you.
The pricing modifier tells the payer who did the work and how many cases the anesthesiologist directed at once. Medicare allows 100% for a personally performed case and 50% to each side of a directed one.
Pricing modifiers go first and informational ones second, per Noridian's modifier guidance. Codes are described in our own words; check the current code set and your contractor's guidance.
| Billing situation | Code or modifier (our wording) | Medicare rule | Typical denial or underpayment trigger |
|---|---|---|---|
| Anesthesiologist alone | AA | 100% of the allowance | Pricing modifier missing or not first |
| Anesthesiologist directs one CRNA | QY with QX (CRNA) | 50% to each side; physician documents the seven 415.110 conditions | One side not billed; no record of presence at induction and emergence |
| Two to four overlapping cases | QK with QX (each CRNA) | 50% to each side; four cases at most | Concurrency not in the record; real ratio higher than billed |
| More than four overlapping cases | AD (medical supervision) | Three base units (42 CFR 414.46(f)), plus one time unit if presence at induction is documented | QK billed when the ratio was five or more |
| CRNA without medical direction | QZ | 100%; paid to the CRNA or an employer, on assignment only | QZ used while an anesthesiologist was directing |
| Monitored anesthesia care | QS; G8 (deep or complex surgery); G9 (severe heart or lung history) | Informational; reported after the pricing modifier | Informational modifier first; need for MAC not documented |
| Physical status | P1 to P6 | Not used by Medicare; no modifier units | Posting expects extra units Medicare does not pay |
| Sedation for a spine injection | 01992 (anesthesia for a block or injection another clinician performs, patient prone) | LCDs treat sedation as rarely needed or not reasonable | Same-day 01992 with facet, denervation or epidural procedures (RAC topic 0229) |
Sources: eCFR 42 CFR 414.46, 414.60, 415.110 (2026); CMS claims manual ch. 12 s. 50 via Transmittal 3747 (2017); First Coast (2026); Noridian JF (2025, 2026); CMS RAC topic 0229 and NCCI manual ch. II (2026); AAPC (01992). Rules vary by payer.
Under 42 CFR 415.110, for each case the anesthesiologist must perform the pre-anesthetic exam, prescribe the anesthesia plan, take part in the most demanding parts (including induction and emergence when they apply), ensure a qualified individual does any part they do not, monitor at frequent intervals, stay physically present and available for emergencies, and provide indicated post-anesthesia care. Only the physician can document that these were met.
Concurrency is how many cases one anesthesiologist directs at once, and it sets QY, QK or AD. Noridian asks that records clearly show that number. For AD, Medicare adds one time unit when the physician documents presence at induction, per section 50 of the claims manual (CMS Transmittal 3747) and First Coast, a Medicare contractor. UnitedHealthcare's commercial policy does the same. A teaching anesthesiologist with one resident case, or two concurrent ones, is paid in full under 42 CFR 414.46(e).
P1 to P6 describe the patient's physical status. Noridian lists them as not used by Medicare. UnitedHealthcare's 2026 commercial policy and the North Dakota Medicaid manual (January 2026) also treat them as informational. Code them accurately, but confirm each contract before expecting extra units.
A CRNA working without medical direction bills QZ, which Noridian pays at 100%; UnitedHealthcare's commercial policy pays 85%. Under 42 CFR 414.60, Medicare pays the CRNA or an employer, on assignment only. 42 CFR 482.52 requires hospital CRNAs to be supervised by the operating practitioner or an immediately available anesthesiologist, unless the state's governor opted out. That is a hospital condition, not medical direction.
A postoperative pain block is billed separately only when the surgeon asked for pain help and the block was not the anesthetic. If it was the anesthetic, it is part of the anesthesia service.
The 2026 NCCI policy manual, chapter 2, sets the conditions. An epidural qualifies only under general anesthesia; a peripheral nerve block qualifies under general, spinal or epidural anesthesia. The intraoperative anesthesia must not depend on the block. A block is not separate when the mode was monitored anesthesia care, moderate sedation or a nerve block, and a block placed for intraoperative pain stays included. Append 59 or XU to the block code; a nerve block on the day of surgery needs its own procedure note.
Time matters too. Under the NCCI manual, separately reportable work done before anesthesia time starts or after it ends is not anesthesia time, and UnitedHealthcare's commercial policy does not add block placement time before induction or after emergence. For continuous epidural infusions, 01996 (daily management) is reported only on days after the catheter goes in, one unit per day.
CMS's April 2026 MLN booklet says to use 59 only when no more specific X modifier fits, never just to bypass an edit; see our explainer on modifiers 25 vs 59. Blocks often accompany joint and abdominal surgery, so we coordinate with the surgeon's billing; see our orthopedic billing services and general surgery billing services pages.
Catch problems before the patient reaches the operating room: coverage on the date of service, the surgery's authorization, network status and payer limits.
Anesthesia often rides on the surgeon's authorization. North Dakota Medicaid, for example, requires no separate authorization for anesthesia and matches out-of-state anesthesia claims to the surgical approval. Other plans set their own rules. Our prior authorization guide covers the general process, and our insurance verification guide covers eligibility.
Network status matters under the No Surprises Act. Under 45 CFR 149.420, anesthesiology is an ancillary service: for patients with group or individual coverage, an out-of-network anesthesia clinician at an in-network facility cannot use notice and consent to bill more than the plan's cost sharing. See our out-of-network billing guide.
| Check | Why it matters | Source | What the VMA or biller does |
|---|---|---|---|
| Coverage on the date of service | Anesthesia is not covered when the procedure is not | Noridian JF (2026) | Eligibility checked; plan matched to the face sheet |
| Surgery authorization on file | Some payers tie anesthesia to the surgical approval | North Dakota Medicaid (2026), example | Surgeon's authorization number noted on the case |
| Network status at the facility | Ancillary service: no notice-and-consent balance billing | 45 CFR 149.420 | Status recorded; patient billed no more than cost sharing |
| Screening or diagnostic colonoscopy | 00812 for screening; 00811 with PT when screening becomes diagnostic | Noridian JF (2026) | Visit type flagged; coding follows the final procedure |
| Sedation for a spine injection | LCDs: rarely needed or not reasonable; RAC 0229 denies same-day 01992 | Noridian (2025); CMS RAC 0229 (2026) | Anesthesiologist documents need before booking |
| Labor epidural (01967) time caps | 435 minutes (UnitedHealthcare commercial) vs 75 (North Dakota Medicaid) | UHC 2026R0032A; ND Medicaid | Each payer's cap loaded into expected payments |
| Pre-anesthesia evaluation | Hospital rule: within 48 hours before surgery; medical direction needs the physician's exam | 42 CFR 482.52; 415.110 | Missing evaluation flagged before billing |
Sources: Noridian JF (2025, 2026); North Dakota Medicaid manual (January 2026); UnitedHealthcare policy 2026R0032A; CMS RAC topic 0229 (2026); eCFR 45 CFR 149.420, 42 CFR 482.52 and 415.110. Check each member's current plan.
See what denials and underpayments cost you
Enter your volume and denial rate to estimate what your anesthesia group is losing.
Keep billing in-house if you have an experienced anesthesia coder and records arrive reliably from every facility. Use a billing-only vendor if claims are your only gap. Choose a combined partner when problems start before the case.
| Job | In-house team | Billing-only vendor | Four-pillar partner (RCM Finder) |
|---|---|---|---|
| Pre-case coverage and network checks | Facility front desks, if anyone | Usually left to the group | VMA checks each scheduled case |
| Collecting records from facilities | Staff chase paper and portals | Bills what the group sends | VMA chases gaps; portal holds incomplete cases |
| Minutes, ratios and pricing modifiers | Depends on one experienced coder | Vendor coders, after the fact | Checked against the concurrency log before submission |
| Postoperative block claims | Easy to miss or over-bill | Billed if the record is clear | Request, mode of anesthesia and 59 or XU checked |
| Facility, surgeon and recruiting presence | Rarely anyone | Not included | Marketing pillar for partners and recruits |
| Cost structure | Salaries, benefits, turnover | Varies; ask how fees are set | Quoted after a free practice audit |
Whichever model you choose, track denials by reason and underpayments by payer, every month.
We start with a free audit and change nothing until you see the findings. We build our billing pipeline around how claims actually move through a practice: registration, charge entry, submission, payment and follow-up. For anesthesia, we add the time, ratio and modifier checks on this page.
We compare recent cases, remittances and denials with your anesthesia records.
We put a Business Associate Agreement in place before accessing patient data. Then our team works inside your existing EHR (for example PrognoCIS, eClinicalWorks or athenahealth) and our portal.
We list each facility's face-sheet source and each contract's anesthesia terms: conversion factor, QZ rate, physical status and labor caps.
VMAs check coverage and network status before cases. Claims are coded from the record, scrubbed, submitted and worked to payment.
Each week we review denials by reason, A/R days, unbilled cases and underpayments, and adjust rules where cases stall.
Talk to us about your anesthesia group
Tell us your facilities, your CRNA model and your hardest payer. We will tell you honestly whether we fit.
Any billing vendor that handles your patients' data is a HIPAA business associate. Get a Business Associate Agreement before any access, and ask how access is limited and logged.
HHS guidance names billing, claims processing and practice management as business associate work, and subcontractors need their own agreement. The minimum necessary standard limits use to what each task needs. The Security Rule's technical safeguards require access control, audit controls, integrity controls, person or entity authentication and transmission security.
We use role-based access, audit logging and encrypted (HTTPS) connections, and we put a Business Associate Agreement in place before accessing patient data. For your own side, use our HIPAA compliance checklist for medical practices.
We would rather tell you now than after you sign. Here is where we fit and where we do not.
A good fit if you are
Probably not a fit if you are
What we would do first if we were running your practice's revenue cycle tomorrow.
Before we touch a denial, we line up each anesthesiologist's overlapping cases by the minute. That log decides QY, QK or AD, and reviewers ask for it first.
Only the physician can document the seven conditions. We ask groups to add induction, emergence and availability fields to the record, so the attestation is never an afterthought.
Payers convert minutes themselves. We reconcile start and stop times with the record, so the claim's minutes match the chart.
We check the surgeon's request, the mode of anesthesia and a separate block note. If any is missing, the block stays inside the anesthesia service.
Conversion factor, QZ rate, physical status handling and labor caps differ by payer. We load them into expected-payment rules so underpayments surface at posting.
When a pain physician asks for sedation on a facet or epidural case, the anesthesiologist documents the need before booking.
They cover charge entry from the anesthesia record, coding, claim scrubbing, submission, payment posting, denial management and A/R follow-up. For anesthesia, that also means converting minutes to time units, choosing the right pricing modifier for who performed or directed each case, and billing postoperative blocks only when the rules allow. RCM Finder adds pre-case coverage checks, facility-facing marketing and a claims portal.
Medicare adds the procedure's base units to the time units, then multiplies the total by an anesthesia conversion factor adjusted for your locality. One time unit is 15 minutes, and claims report actual minutes. The ASA's summary of the 2026 final rule lists a national anesthesia conversion factor of $20.4976 for most clinicians. In a medically directed case, each side is allowed 50%.
Medical direction means an anesthesiologist meets seven conditions in 42 CFR 415.110, including the pre-anesthetic exam, presence at induction and emergence, and staying available for emergencies, for one case or up to four concurrent cases. The anesthesiologist bills QY or QK and the CRNA bills QX, each allowed 50% by Medicare. Directing more than four cases at once is medical supervision (AD), paid on three base units, plus one time unit if the physician documents presence at induction.
Yes. A CRNA who is not medically directed bills with modifier QZ, and Medicare allows 100% of the fee schedule amount, the same share as an anesthesiologist working alone. Payment can go to the CRNA or to an employer such as a hospital, group or ASC, and only on assignment. Hospital rules still require CRNA supervision unless the state has opted out. Commercial rates can differ.
Sometimes. Under the 2026 NCCI policy manual, a block for postoperative pain is separately reportable when the surgeon asks for pain help and the block was not the anesthetic. An epidural qualifies only with general anesthesia; a peripheral nerve block qualifies with general, spinal or epidural anesthesia. Add modifier 59 or XU to the block code and keep a separate procedure note.
No. Noridian lists P1 to P6 as not used by Medicare, and the federal anesthesia payment rule allows no modifier units. UnitedHealthcare's 2026 commercial policy also treats them as informational, and North Dakota Medicaid says they do not affect payment. Report them accurately anyway, and check how each of your contracts treats them.
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Pricing is quoted after the audit, based on your volume and the services you choose. Prefer to talk? Call +1 (302) 556-2288.
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