Anesthesia Coding Alert

Qualifying circumstances can boost pay in some cases.

Qualifying circumstances codes might not be reimbursed by traditional Medicare, but some private payers and Medicare Replacement Plans pay for the additional units associated with codes such as +99100 (Anesthesia for patient of extreme age, younger than 1 year and older than 70 [list separately in addition to code for primary anesthesia procedure]). The next time your anesthesiologist helps care for a patient of extreme age, keep the following advice in mind to know how to handle the situation.

Narrow the Age Parameters

You should use +99100 only in certain age-related situations. Report it along with the anesthesia procedure code when your physician works with an infant or an adult older than 70 years of age. Coders sometimes debate what “older than 70” means; is it after the patient’s seventieth birthday, or in other words, after the patient has turned 70 years old.

“The terminology means anyone who is 70 years old on the date of service,” offers Catherine Brink, BS, CMM, CPC, president of Healthcare Resource Management in Spring Lake, NJ. “A patient can qualify for +99100 when he isone day past 70 and beyond that date. You don’t have to wait until he is 71 or older.”

Another tip: “Younger than one year” in code descriptors means up to the date of the patient’s first birthday.

Double Check for Service Inclusions

Pay attention to an important guideline associated with reporting +99100: CPT^® states that you cannot report +99100 for anesthesia during a hernia procedure performed on infants younger than 1 year of age. Instead, you should report anesthesia codes 00834 (Anesthesia for hernia repairs in the lower abdomen not otherwise specified, younger than 1 year of age) or 00836 (Anesthesia for hernia repairs in the lower abdomen not otherwise specified, infants younger than 37 weeks gestational age at birth and younger than 50 weeks gestational age at time of surgery), depending on the circumstances.

The same guideline applies to larynx/trachea cases on infants: submit 00326 (Anesthesia for all procedures on the larynx and trachea in children younger than 1 year of age) instead of +99100.

Although CPT^® guidelines don’t list other codes you should steer clear of with +99100, you also cannot report it with 00561 (Anesthesia for procedures on heart, pericardial sac, and great vessels of chest; with pump oxygenator, younger than 1 year of age). The descriptor already mentions the patient’s age, which make including +99100 a moot point.

Explanation: The descriptors for the anesthesia codes recognize the complexity in providing these services for infants. Reporting the standard anesthesia codes also means that providers get reimbursed for units they might be paid for by adding +99100 to the claim. Codes00326, 00834, and 00836 each include an additional unit of valuation to recognize the work associated with +99100.

Don’t Give Up on Payers

Traditional Medicare does not pay additional units for qualifying circumstances codes, but that doesn’t mean all hope is lost.

“You cannot bill +99100 to Medicare for a patient over 70 who has Medicare as their primary insurance,” Brink says. “Medicare will not pay, but if the patient has another insurance as primary it will be up to the payer.”

Some state Medicaid plans might pay for +99100, but you should check with your local state carriers to see if they publish a policy regarding payment. If a payer denies the claim with +99100, be prepared to appeal with documentation.