# MAC Modifiers QS, G8 and G9 - Would someone please



## diane1217

Hi all,
Would someone please be so kind as to offer some assistance regarding Medicare and use of the QS, G8 and G9 modifiers to use for MAC anesthesia?  I have read the Palmetto/CMS guidelines over and over and over, each different coder here each has their own different interpretation as to the proper usage of each modifier with the 25 MAC codes, and the "special" 6 codes of 00100, 00160, 00300, 00400, 00532, 00920.  Also, is the use of comorbidity dx's required at any time with these modifiers?  I appreciate ANY input.
Thanks so very much!
Diane


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## jdrueppel

What state are you billing for?  Every MC carrier has the authority to interpret the local policy.  If I can look at your local carrier guideline I should be able to help you.  I have billed anesthesia for 18 years and, currently, we do not have a MAC policy YEA! but I'm sure one will be forthcoming.

Julie, CPC


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## jdrueppel

OK - I'm not a patient woman so I read both of the Palmetto GBA policies (LCD L27707 and L28279) and they are identical.  These policies are very similar to the policy that was effective for my state (Nebraska) up until 3/1/08.

Basically, in addition to the AA modifier (you noted on your Anesthesia thread that you are an MDA practice),on EVERY MAC service you need to append either the QS, G8 (markedly deep or invasive), OR G9 (history of severe cardiopulmonary disease).  
On ASA codes, Palmetto will allow you to automatically assign the G8 modifier to ASA codes 00100, 00160, 00300, 00400, 00532, and 00920.  
On the other ASA codes listed in this policy (which does not include all ASA codes) you will need to assign either QS, G8 or G9.  
No additional diagnosis from the list of covered diagnosis is necessary if appending the G8 or G9 modifier. (Personal note - I NEVER appended to G9 modifier without verifying first with my anesthesia provider as I didn't feel comfortable based on the limited documentation I received for billing purposes).
If appending the QS modifier it IS NECESSARY to include a covered diagnosis from the policy list.  You will continue to report your surgical diagnosis and the covered diagnosis would be your secondary or tertiary code.  Please note #7 instruction on the policy
7. The presence of an underlying condition alone, as reported by an ICD-9-CM code, may not be sufficient evidence that MAC is necessary. The medical condition must be significant enough to impact the need to provide MAC, such as the patient being on medication or being symptomatic, etc. The presence of a stable, treated condition of itself is not necessarily sufficient.
For example - if the patient is hypothyroid and is on thyroid replacement (i.e. Synthroid) I would code244.9 as my covered diagnosis
Keep in mind that the * diagnosis from the list have further clarification at the bottom of the covered diagnosis list. 
Although it would be easier, it is NOT APPROPRIATE to automatically append the G8 (except as currently instructed by your local policy) or G9 modifiers.  It is important for your coders to have a current copy  (diagnosis were frequently added to our policy) and complete understanding of this policy.  
Medicare will deny those services not meeting these guidelines as not medically necessary (provider write off unless ABN is signed).  There is some wiggle room for appeal but it may or may not warrant payment by your Medicare carrier.  But that would be another conversation which I would happily have with you in person it you feel necessary.
Sorry I couldn't condense this but this policy was a thorn for us so I wanted to thoroughly explain the policy.
If you have questions feel free to send me a private message with your phone number and the best time to contact you.
Julie, CPC


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