Anesthesia Coding Alert

Medicare Won't Pay, but Others Might

 If Medicare covers the bulk of your patients, you might not think to add qualifying circumstances (QC) codes to claims when it's appropriate because Medicare doesn't reimburse for them. But leaving QC codes off claims you submit to non-Medicare carriers which do reimburse for qualifying circumstances is a mistake you don't want to make.

 Many anesthesiologists provide services in particularly difficult circumstances, such as during a liver transplant for a patient with end-stage liver disease. The qualifying circumstances codes reflect some of that added difficulty and help the anesthesia provider receive more appropriate reimbursement for services.

 The anesthesia-related QC codes include:
 

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

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

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

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

 Since these are classified as add-on (or secondary) codes, you report them in addition to the anesthesia code for the procedure. You can also use QC codes with surgical CPT codes (whether you're using surgical codes because the carrier requires them or because the anesthesiologist performed a surgical-type procedure such as a pain relief injection), says Emma LeGrand, CCS, CPC, office manager for New Jersey Anesthesia Associates in Florham Park. Just be sure to submit the claim with 7"" (anesthesia) as the type of service if you're reporting anesthesia care with surgical codes.

 In what real-life situations can the QC codes be used? LeGrand; Darlene Isom" billing supervisor in the anesthesia department of Northwestern Medical Faculty Foundation Inc. in Chicago; and Lori Mehlbauer an anesthesia coder in Louisville Ky. offer these examples for when you're dealing with non-Medicare carriers.
 

99100 Use this code for any case on a patient younger than 1 year of age or older than 70 provided it isn't a hernia-related case (reported with 00834 or 00836 instead) or a larynx/trachea case (reported with 00326) on the infant (see below for more information). "You should report 99100 when the record clearly documents unusual risk factors associated with the patient's age condition and anesthesia risk " Isom says.

 

99116 Deliberate hypothermia is an effective way to decrease oxygen-level requirements during surgery and decrease the incidence of postoperative neurological injury after neurosurgical and cardiac procedures. Anesthesiologists often induce total body hypothermia for cases such as coronary artery bypass graft surgery (CABG 33503-33505 33510-33516 33517-33523 and 33533-33536) surgery to repair complex congenital defects in children and neurosurgery. Anesthesiologists always let the patient's body temperature drop a few degrees but this is not hypothermic surgery. Proving that the induced hypothermia is a separate billable procedure is one of LeGrand's greatest challenges with using QC codes. Work your way around it by ensuring the physician's documentation is clear and shows medical necessity for hypothermia.

 

99135 Deliberate hypotensive anesthesia is a safe and effective way to decrease surgical blood loss and surgical time. It also reduces the need for blood transfusion when the anesthesiologist anticipates excessive blood loss such as during procedures on the head face or upper thorax total hip replacement surgery (27130-27132) aneurysm clipping and scoliosis surgery. The anesthesiologist usually inserts an arterial line or A-line (36620 Arterial catheterization or cannulation for sampling monitoring or transfusion [separate procedure]; percutaneous) during hypotensive anesthesia to monitor the patient's blood pressure.

 

99140 Postoperative complications that mean a return to surgery can qualify for 99140 as can post-partum complications or trauma cases. Even so many coders are careful about reporting 99140 because of the need for clear documentation of an emergency. "We're really careful about how and when cases qualify for 99140 " Mehlbauer says. "We have lots of hand cases that are obviously emergencies (such as when the patient's finger has been cut off) so we definitely use 99140 then. But our physicians won't always classify post-op bleeding as an emergency if the bleeding doesn't complicate the anesthesia."

Follow CPT's Notes About QC Codes

 CPT's qualifying circumstances guidelines include two important notes. CPT states that you no longer report 99100 for anesthesia during a hernia procedure performed on infants younger than 1 year. Instead you report new anesthesia code 00834 (Anesthesia for hernia repairs in the lower abdomen not otherwise specified under 1 year of age) or 00836 (Anesthesia for hernia repairs in the lower abdomen not otherwise specified infants less than 37 weeks gestational age at birth and less than 50 weeks gestational age at time of surgery). (The CPT note says to use 00833 and 00834 but 00833 does not exist. A correction saying to use 00834 and 00836 is on the American Medical Association's Web site.) The same applies to new code 00326 (Anesthesia for all procedures on the larynx and trachea in children less than 1 year of age) it can't be used in conjunction with 99100.

 "The code changes recognize the anesthetic complexity involved in providing services for infants " LeGrand says. They also mean that anesthesia providers now get reimbursed for units they previously missed out on if the carrier didn't recognize QC codes. The new codes' unit values equal the old codes' values plus one unit for 99100.

 The second note in the QC section relates to code 99140 and defines an "emergency" as "existing when delay in treatment of the patient would lead to a significant increase in the threat to life or body part." That looks great on paper but quantifying "significant increase in threat" can be challenging for providers and coders alike.

 "The diagnosis procedure and patient's condition quantify 'significant increase in threat to life of the patient ' " Isom says. Factors including abnormal blood pressure infection surgical complications blood loss and problems involving the vascular cardiac or neurological systems help determine whether a condition is a "threat to life." Spinal fractures; skull fractures with subdural epidural or intracranial hemorrhage; and other conditions that the physician must deal with immediately all qualify as emergencies.

 "Some physicians believe that deliveries should all be billed as emergency procedures but the insurance carriers do draw the line for billing emergency conditions during deliveries " Isom says.

 Even if the case is obviously an emergency (such as a liver transplant 47135 Liver allotransplantation; orthotopic partial or whole from cadaver or living donor any age) the anesthesiologist must document "emergency" on the patient's chart before you can use 99140.

 Also check the terminology of your carrier policies some pay for "unusual hours" rather than "emergency " 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.

So Who Pays and Is It Worth It?

 Medicare does not reimburse for QC codes. But this is one area where Medicaid and many nongovernment payers don't follow Medicare's no-payment guidelines and actually reimburse providers. The values range from one additional unit for code 99100 and two units for 99140 to five units for codes 99116 and 99135. These extra units can add up nicely but carriers might handle the situation differently. You can help determine what codes will be accepted and what your reimbursement will be by negotiating fees for QC as part of your non-Medicare contracts.

 Mehlbauer's group gets paid according to the ASA Relative Value Guide (RVG). "We include a clause in our contracts about it. If we get denials we send the carrier a copy of the ASA RVG and remind them of our contract. The denials are usually just because someone on the carrier end wasn't familiar with our contract or the policy."

 LeGrand says that education is the key when negotiating QC payments: "We must try to educate the carriers to understand that anesthesia services involve increased work and risk and that cases that merit qualifying circumstances codes warrant addi-tional compensation."