HCPCS (Procedure & Global Package) Updates

CPT code set changes in 2025 were substantial overall—with 270 new codes, 112 deletions, and 38 revisions—but none were specifically identified as labor-and-delivery related in published overviews. These changes are critical to understanding HCPCS anesthesia codes and anesthesia CPT coding updates.

Category II code

0503F — Post-partum care visit

C Medicaid will require documentation of prenatal care in the patient’s history using anesthesia documentation requirements with Category II codes:

From July 1, 2025, Medicaid claims for delivery will be denied if 0500F (Initial prenatal care visit) is not on record.

BCBSTX (Blue Cross Blue Shield of Texas) has announced a new anesthesia medical and billing guidelines policy —CPCP044, effective August 19, 2025—that covers billing specifics of the global OB maternity services, including antepartum care, delivery services, postpartum care, multiple births, care by different providers, and complications

 The Medicare Physician Fee Schedule

• Medical Anesthesia Conversion Factor 2025 (ACF) 2025: $20.3178 — a drop of about 2.2% from the 2024 rate of $20.7739.
• General MPFS Conversion Factor (non-anesthesia services): $32.3465.
• Under the CY 2025 Medicare Physician Fee Schedule proposed rule, the ACF was initially projected to decrease from $20.7739 to $20.3340 (–2.1%).

• The ASA guidelines 2025 and MIPS/QPP provisions for anesthesiology show no major changes:
  • Performance threshold remains 75 points
  • Data completeness stays at 75% for 2025–2028

Medicare Reimbursement Pressures

The 2025 Medicare Physician Fee Schedule included a 2.2% reduction in the medicare anesthesia medical coding conversion factor, signalling financial pressures. Additionally, some private insurers are capping CRNA billing guidelines reimbursements at 85% of the physician fee schedule.

Who gets paid what (modifier map)

Medicare’s long-standing rule:

• When a case meets medical direction, each of the physicians (QK/QY) and the CRNA/AA (QX) is paid 50% of the personally-performed allowable. (MACs publish this explicitly; see Novitas/Palmetto). Novitas Solutions Palmetto GBA
• CRNA QZ remains personally performed by CRNA (no physician medical direction). (ASA/AANA primers).

Policy reminders that affect payment (2025)

• Bundling / NCCI compliance: Avoid unbundling services that are considered part of anesthesia coding care—such as line placement or drug administration performed between pre-op arrival and PACU discharge. Follow NCCI Chapter 1 and 2 guidelines to prevent denials.
• Medical direction vs. supervision: For medical direction billing, the anesthesiologist must meet Medicare’s requirements—such as directing 2–4 concurrent cases and completing all required steps. If these are not met, the service is billed as medical supervision, which reimburses at a lower rate (per Noridian guidance).
• Commercial plan variations: While many commercial payers, including UHC, follow Medicare’s anesthesia reimbursement changes, each plan may have its own rules on caps, unit counting, and documentation. Always review the payer’s specific reimbursement policy.

2025 payer watch-outs

• United Healthcare change announced for Oct 1, 2025 (state carve-outs listed). Details are still being contested by stakeholders; check your UHC contract/bulletins for how your group is affected.
• MACs post the 2025 participating/non-par anesthesia CFs you’ll use on claims (e.g., WPS, Novitas).
• Anthem Blue Cross Blue Shield (Anthem BCBS) had proposed that, starting with claims processed on or after February 1, 2025, they would use CMS Physician Work Time values to determine the amount of anesthesia time that may be billed. In practice, this meant:

• • Claims that report time exceeding the CMS-determined average would be denied.
  • The evaluation would account for pre-service, intra-service, and post-service anesthesia time, in line with the ASA’s guidelines on documentation
• Anthem clarified that industry-standard coding requirements and the ASA anesthesia formula were not changing.

Quick billing tips (to keep money on the claim)

• Apply the correct anesthesia coding modifiers to each anesthesia line (AA/QZ/QY/QK/QX/AD) based on who actually did what. (Many plans will deny lines missing payment modifiers.
• Document start/stop times and, for medical direction, the required physician involvement; mismatch between documentation and modifiers triggers down-coding to AD Medicare
• For post-op catheter management (01996), bill one unit per day starting the day after insertion (not on insertion day).

Time, units, and payer wrinkles (2025 examples)

• NCCI reaffirms that anaesthesia CPT codes encompass all integral services through PACU discharge by anaesthesia, excluding unbundled line placements, monitoring, etc.
• Some payers cap OB epidural time on a single claim (e.g., UHC Community Plan limits 01967 (±01968) to 360 minutes/24 units—check your contract). UHC Provider
• Example methodology references for adding time to 01967/01968 appear in UHC policy examples; follow your payer’s anesthesia unit rules. UHC Provider

Quick coding scenarios (2025-ready)

• Vaginal delivery after labor epidural
  Report 01967 with actual anesthesia time; do not add 6232X. If a TAP block is done solely for postpartum pain at the surgeon’s request, add 64486–64489 with 59/XU and a clear post-op pain note.
• Labor epidural → converts to C-section
  Report 01967 + 01968 with their respective times. If you also perform a TAP block for postop pain, add 64486–64489 with 59/XU per NCCI.
• Planned C-section (no labor epidural)
  Report 01961 with time. If you place a separate postop analgesia block (e.g., TAP), you may report 64486–64489 with 59/XU when criteria are met. 01996 starts the day after any continuous neuraxial catheter is placed

RVU and Reimbursement Implications

Continuous infusion techniques (e.g., 64467) generally carry higher RVU values than their single-injection counterparts (e.g., 64466). This can positively impact anesthesia reimbursements changes under the 2025 Medicare Physician Fee Schedule. Geographical adjustments via GPCI may further influence reimbursement.

The Fiscal Year 2026 Proposed Rules

Anesthesia Conversion Factor & Payment Adjustments:

1. Split Conversion Factors for 2026

• Starting in CY 2026, CMS proposes two distinct anesthesia conversion factors based on whether the provider is a Qualifying Participant (QP) in an Advanced Alternative Payment Model (APM):
• Anesthesia CF for QPs (APM participants): $20.6754, up 1.8% from the 2025 CF of $20.3178

2. Overall Payment Pressures: Efficiency and Practice Expense Adjustments

While the conversion factor sees a modest increase, other adjustments introduce downward pressure on reimbursements:

• Efficiency Adjustment: CMS proposes a –2.5% cut to work RVUs (and corresponding intraservice physician time) for non-time–based services, based on a 5-year review of the Medicare Economic Index (MEI)
• Practice Expense (PE) RVU Reduction: Anesthesia faces a –1% reduction in PE RVUs for facility settings, with little to no change in work or malpractice RVUs—for an overall estimated net specialty impact of about –1% (excluding CF changes.

3. Net Estimated Financial Impact 

4. Telehealth Policy Updates:

CMS proposes to streamline additions to the Telehealth Services List, remove frequency limits on inpatient/nursing facility/critical care encounters, and allow permanent virtual direct supervision via two-way audio‑video (excluding audio-only) for services requiring direct supervision