Anesthesia Coding Alert

Don't forget add-on codes for non-Medicare carriers

As an experienced anesthesia coder, you know that Medicare doesn't reimburse for qualifying circumstances codes 99100-99140. But don't overlook this chance for additional reimbursement--and more accurate claims--when your anesthesia provider's service is "above and beyond" the norm.

Review the Special Circumstances   

Complicating factors such as patient age, total body hypothermia, and emergency conditions can change how your anesthesiologist cares for a patient. CPT includes four add-on codes that describe these situations, known as qualifying circumstances (QC):

• +99100--Anesthesia for patient of extreme age, under 1 year and over 70 (list separately in addition to code for primary anesthesia procedure)

• +99116--Anesthesia complicated by utilization of total body hypothermia (list separately in addition to code for primary anesthesia procedure)

• +99135--Anesthesia complicated by utilization of controlled hypotension (list separately in addition to code for primary anesthesia procedure)

• +99140--Anesthesia complicated by emergency conditions (specify) (list separately in addition to code for primary anesthesia procedure).

Remember that CPT classifies these as "add-on" codes, which means you must report them with another code for the main procedure, says Leslie Johnson, CCS-P, CPC, a coding consultant in Houston. 

"These QC codes are essentially 'added risk' codes that are inherent to the case at hand (such as emergency and age)," Johnson adds. "These extraordinary risks won't necessarily be found within the provider's written documentation as being actually present; they exist by virtue of the condition and circumstance happening all at the same time."

Age note: CPT and ASA guidelines state that you cannot report 99100, 99116 and 99135 with 00561 (Anesthesia for procedures on heart, pericardial sac and great vessels of chest; with pump oxygenator, under one year of age). The descriptor and base units for 00561 already account for the patient's age and associated risk factors, so you don't need additional QC codes to explain the circumstances.

Wade Through Carrier Guidelines for QCs 

Carriers often follow Medicare's lead on whether to reimburse for certain codes or diagnoses, but that's not always the case with qualifying circumstances codes. Consider the following examples of times when insurers might reimburse you for QC codes.

• United Healthcare and some Medicaid carriers accept 99140 when you report it with certain diagnoses. 

- First-time patient: A patient presents with a traumatic amputation of her leg. She is at risk for shock and decrease in body temperature, which means the anesthesiologist might need to provide additional care to keep the patient stable. Your carrier might accept 99140 along with diagnosis 897.x (Traumatic amputation of leg[s] [complete] [partial]). 

- Follow-up patient: Sometimes patients have postoperative bleeding (998.11, Hemorrhage complicating a procedure), shock (998.0, Postoperative shock) or other problems that require a return trip to the operating room (OR). These situations raise the patient's emergency status and increase the anesthesiologist's risk in providing care. Most carriers will usually pay for 99140 in these types of situations, Johnson says.

• Texas Medicaid allows payment for all QC codes but will not reimburse for 99140 if you list diagnosis codes 650 (Normal delivery) or 669.70 (Cesarean delivery, without mention of indication; unspecified as to episode of care or not applicable) as the referenced diagnosis. The referenced diagnosis on your claim must indicate the complicating condition.

"True obstetric emergencies are from abruption, severe eclampsia and bleeding," says Scott Groudine, MD, an Albany, N.Y., anesthesiologist. Expect diagnoses in these cases such as 641.1-641.9 (diagnoses associated with placenta previa, premature separation of placenta and antepartum hemorrhage) and 642.5x (Severe pre-eclampsia).

Your carrier might also accept other diagnoses supporting emergency cesarean sections. These diagnoses could include:

• Macrosomia--653.5x (Unusually large fetus causing disproportion)

• Pyrexia--659.2x (Maternal pyrexia during labor, unspecified)

• Non-reassuring fetal heart rate--659.7x (Abnormality in fetal heart rate or rhythm)

• Failure to progress (661.2x, Other and unspecified uterine inertia).
 
• Aetna allows payment for 99116 and 99135. But if you're filing a claim for service prior to June 24, 2005, some coders warn that you shouldn't expect payment for 99100 or 99140. Aetna will, however, pay for 99100 and 99140 for services on or after June 24, 2005.

Johnson has never had problems with Aetna reimbursing these codes if the diagnosis warrants the need for emergency care. "I wonder if this is a state-specific guideline," she asks.

Tip: Also check the terminology of your carrier's policies--some pay for "unusual hours" rather than "emergencies," which can be easier to document and justify. A note from the surgeon indicating the potential for life or limb impairment with delayed surgery also helps justify using 99140.

Submit QC Codes No Matter What

Even if your carrier won't reimburse for QC codes, Johnson recommends that you still include the appropriate code on your claim.

"Oftentimes, carriers will not reimburse (or will pay at a lower rate) based on what they perceive others in the same specialty are doing," Johnson says. "If everyone quits billing for a procedure, that code will no longer be allowed. If everyone continues to bill for the procedure, it's likely that insurance carriers will see the procedure as a viable and billable service, and thus allow it."

Exceptions: As with most coding rules, this reporting-whether-you'll-get-paid-or-not tactic has its exceptions. Johnson has two cases when she does not automatically add QC codes to her claim:

• When Medicare and Medicare-following carriers explicitly state that a specific code is not payable under any circumstances at all.

• Cases involving diagnosis 650 (Normal delivery) and procedure 99140.

"The anesthesiologists are famous for reporting 99140 just because the patient is in routine labor," Johnson says. "They can't communicate the need for an emergency code with diagnosis 650, and Texas Medicaid won't pay for it. Without definitive reason, I wouldn't report 99140 with diagnosis 650.

"If there's a real reason for reporting an emergency, the physician should document that reason, and we would report another diagnosis code that tells the carrier that the delivery was not routine."

Fight for Your Physician's Rights   

Taking steps to learn all of your different carriers' guidelines for QC codes can be tedious and time-consuming. But when you consider that QC codes will add one, two or five extra units to your procedure code (depending on which QC code applies), knowing which carriers recognize the services definitely pays off.

Be up-front: Be sure to discuss qualifying circumstances when you negotiate contracts with Medicaid or non-government carriers. Some groups recommend including a clause in your contract stating that the carrier reimburses based on the ASA Relative Value Guide. Then if you receive a denial, make a copy of the RVG page and remind the representative of your contract.

Bottom line: Education is a must when you're negotiating QC payments. Anesthesia services involve increased work and risk, and cases that merit qualifying circumstances warrant additional reimbursement.