Anesthesia Coding Alert

Modifiers are an integral part of coding for anesthesia practices. Some, such as physical status modifiers, should be filed with each procedure as appropriate. Other modifiers that further explain the situation are used often as well. These modifiers are divided into three groups:

Level I, or CPT, modifiers are two numeric digits, such as -22, (unusual procedural services).

Level II national modifiers are two alphabetic digits (AA-VP). They are recognized by carriers nationally and are updated each year by the Health Care Financing Administration (HCFA).

Level III, or local, modifiers are assigned by individual Medicare carriers and are shared with physicians and other providers through carrier newsletters. Individual carriers may change, add or delete these local modifiers as needed.

The Level I modifiers most often used for anesthesia were discussed in the article Correct Usage of Modifiers Can Optimize Reimbursement, page 3 in the January 2000 issue of Anesthesia Coding Alert. In this issue we discuss the Level II modifiers most appropriate to anesthesia as found in HCPCS 2000.

Deleted Medicare Modifiers

Several modifiers that applied to anesthesia have been deleted from HCPCS 2000. Walter Pritchard, administrator at Anesthesia Service of Eugene, a 29-physician anesthesia group in Eugene, Ore., thinks this shows HCFAs attempts to keep the list aligned with the modifiers most practices use. Many of these deleted modifiers werent really used anyway, he says. They have not been used for some time, and this just makes it official.

Several of the deleted codes related to cases that were medically directed. Pritchard and Barbara Bastin, office manager of the physician group Greenwich Medical Anesthesia and University Pain Center in New York, N.Y., recommend using these codes in their place:

-AB (medical direction of own employee[s] by anesthesiologist [not more than four employees.]) This modifier was used only for state Medicaid cases, not for Medicare. We never used this modifier anyway, Bastin says. We havent used this in years, Pritchard adds. We use modifiers -QK or -QY instead. (see below)

-AC (medical direction of other than own employees by an anesthesiologist [not more than four individuals]). The physicians in Pritchards group only direct their own employees, so he says they have never used this modifier either.

-AE (direction of residents in furnishing not more than two concurrent anesthesia servicesattending physician relationship met). Neither Bastin nor Pritchard had been using this modifier. Empire Blue Cross/Blue Shield in New York doesnt accept this modifier, says Bastin. Weve always used -QK instead.

-AF (anesthesia complicated by total body hypothermia). Bastins group used this modifier only for state Medicaid claims, not for Medicare cases. She says New York state still accepts it; other states may be the same, so check with your local carrier. Pritchard advises using code 99116 (anesthesia complicated by utilization of total body hypothermia [list separately in addition to code for primary anesthesia procedure]) instead.

-AG (aesthesia for emergency surgery on a patient who is moribund or who has an incapacitating systemic disease that is a constant threat to life [may warrant additional charge]). Pritchard says he uses the physical status modifiers (P3-P5) listed in CPT 2000.

The New Medicare Modifiers

Two new modifiers for anesthesia are included in HCPCS 2000, but went into effect in July 1999. It is important to note that they are discretionary, so all carriers may not have adopted them. (Pritchard, for instance, does not use either of the new modifiers because the Oregon carrier does not require them.) Your local carrier can tell you whether they are necessary in your state.

If they are required in your area, they must be used in addition to the -QS modifier for monitored anesthesia care service (MAC), plus the appropriate anesthesia payment modifier for whether the procedure was personally performed or medically directed. It must also be matched with an ICD-9 code that supports medical necessity.

If the new modifiers are not required by your carrier, MAC cases should still be reported using the -QS modifier, as in the past.

-G8 (MAC for deep complex, complicated, or markedly invasive surgical procedures). For example, if a CRNA performs MAC on a patient during a breast biopsy under the medical direction of an anesthesiologist, the procedure would be reported for the breast biopsy as code 00400 (anesthesia for procedures on the integumentary system on the extremities, anterior trunk and perineum; not otherwise specified) -QX (CRNA service: with medical direction by a physician) -QS (MAC) -G8.

-G9 (MAC for patient who has a history of severe cardiopulmonary condition). For example, if an anesthesiologist performs MAC unassisted for a bronchoscopy with biopsy on a patient with a history of congestive heart failure, the procedure would be reported as 31625 (bronchoscopy, [rigid or flexible]; diagnostic, with or without cell washing [separate procedure]; with biopsy)
-AA (anesthesia service performed personally by anesthesiologist) -QS (MAC) -G9.

Other Modifiers Still in Use

In addition to the new -G8 and -G9 modifiers, a number of Medicare/Medicaid modifiers remain the same in 2000. Most apply nationally, but some may be used only by local Medicaid carriers. Oregon, for example, does not allow these modifiers for state Medicaid cases, so Pritchard does not use any of them for those claims. As with other coding issues, check with your local carrier to learn which ones apply in your state and how they should be reported in conjunction with procedure codes.

-AA (anesthesia services performed personally by an anesthesiologist). Bastin says most of their claims qualify for this modifier, so they, like many practices, use it quite often. Pritchard uses it for all Medicare claims as appropriate.

-AD (medical supervision by a physician: more than four concurrent anesthesia procedures). This modifier does not usually apply to the services offered by Bastins group. Pritchards group also rarely uses it.

-QK (medical direction of two, three, or four concurrent anesthesia procedures involving qualified individuals). Both Pritchard and Bastin frequently use this modifier for medical direction of Medicare claims.

-QS (monitored anesthesia care service). Bastin and Pritchard agree that this modifier should be used on all Medicare claims for MAC. As noted above, the -QS modifier is used for all MAC cases, whether the new -G8 and -G9 modifiers are required locally or not.

-QX (CRNA service: with medical direction by a physician). Pritchard says the Oregon carrier requires this modifier on all Medicare claims when appropriate. However, Bastins group does not use itjust another example of how carriers in different states may require different documentation.

-QY (medical direction of one CRNA by an anesthesiologist). This modifier is to be used on all Medicare claims when appropriate.

-QZ (CRNA service: without medical direction by a physician). Neither Bastin nor Pritchard uses this modifier in their groups, because their physicians always medically direct the work of their CRNAs. However, it is used by a number of practices that do have CRNAs performing services without medical direction. One example of its use is a CRNA who performs anesthesia services in a rural setting but does not have an anesthesiologist at the facility to perform medical direction. In these situations, the surgeon performing the procedure is often responsible for supervising the CRNA.

Anesthesia practices may use other modifiers from time to time, depending on the groups situation and the state where the services are provided. For example, Bastins group also uses the -GC modifier for cases that are performed in part by a resident under the direction of a teaching physician.

Whichever modifiers you use, Pritchard points out that you need the necessary documentation to support medical direction for concurrency billing. And as with anything related to coding, it is important to be familiar with your carriers requirements so procedures are reported in the most accurate, appropriate way for your area.