Anesthesia Coding Alert

HCPCS 2001 states that modifiers should, or in some cases must, be used to identify circumstances that alter or enhance the description of a service or supply. Yet, local medical review policies (LMRPs) and private-carrier requirements on the use of modifiers on anesthesia claims vary from state to state. For anesthesia coders, one of the biggest challenges is knowing how to apply Level II modifiers, defined as HCPCS/national modifiers comprising two alphabetic or alphanumeric digits. They are recognized by carriers nationally and are updated annually by CMS.

Modifiers for Monitored Anesthesia Care (MAC)

 
Kelly Dennis, CPC, of Central Florida Anesthesia Associates of Leesburg, Fla., and president of the Florida Anesthesia Administrators Association, notes, When modifiers -G8 and -G9 first came out in 1999, it appeared as if they were for surgical reporting. After calling our local Medicare carrier, First Coast Options, I learned we do report these modifiers with our anesthesia codes."

Using Modifier -G8

 
-G8 -- monitored anesthesia care (MAC) for deep complex, complicated, or markedly invasive surgical procedure.
 
 
Dennis states that this modifier is appended to the anesthesia code associated with the surgical procedure. These include:
 

00100 -- anesthesia for procedures on salivary glands, including biopsy

00160 -- anesthesia for procedures on nose and accessory sinuses; not otherwise specified
 

00300 -- anesthesia for all procedures on the integumentary system, muscles and nerves of head, neck, and posterior trunk, not otherwise specified
 

00400 -- anesthesia for procedures on the integumentary system on the extremities, anterior trunk and perineum; not otherwise specified
 

00532 -- anesthesia for access to central venous circulation
 

00920 -- anesthesia for procedures on male genitalia (including open urethral procedures); not otherwise specified.
 
Dennis says, "A common example involves breast biopsy. If one of our anesthesiologists personally performs the procedure, it is common for us to report it as 00400-AA-G8." Deborah Hecht, CCSP, assistant administrator with Professional Anesthesia Services of Akron, Ohio, adds that Ohio and West Virginia's Medicare carrier, Nationwide Medicare, also uses this modifier. "The implementation of modifier -G8 has saved us a lot of headaches, especially with getting breast biopsy claims paid," Hecht says.

Using Modifier -G9

 
-G9 -- monitored anesthesia care for patient who has history of severe cardiopulmonary condition.

 
This modifier is more straightforward. In an LMRP regarding MAC, Nationwide Medicare states, "Use modifier -G9 in conjunction with the appropriate CPT code to denote any surgical procedure in which MAC is used when the patient has or had a severe cardiopulmonary condition, or there is a significant risk for an exacerbation of an underlying cardiopulmonary condition during the procedure, in a stable patient."
 
"We always use the modifier when MAC is performed during surgery for a patient with cardiovascular disease. For example, for pacemaker insertion, again with anesthesia personally performed by the anesthesiologist, we report 00530-AA-G9," Dennis says.  

Note: 00530, anesthesia for permanent transvenous pacemaker insertion.
 
Some coding experts advise using modifier -QS (monitored anesthesia care service) with either -G8 or -G9. However, Dennis says, "Since -G8 and -G9 already denote MAC, we drop the -QS when we use either of these modifiers." Modifiers -G8 and -G9 are not required by all carriers; if your state doesn't use them, MAC cases should be reported with modifier -QS. "When modifiers -G8 and -G9 are not applicable, we report modifier -QS on all Medicare/Medicaid/Blue Shield claims. Even though -QS was first requested as a 'statistical reporting' modifier, it has become mandatory," Dennis advises.
 
Scott Groudine, MD, an anesthesiologist in Albany, N.Y., notes, "Although some carriers don't require the use of modifier -G8 or -G9, many are considering instituting more restrictive MAC policies. These will require their use, or the presence of a qualifying pre-existing condition to warrant payment for MAC. Some codes under these LMRPs will not be paid if just modifier -QS is used."
 
In all circumstances, the CPT codesfor the procedure must be matched with the ICD-9 codethat supports medical necessity.

Modifiers Describe Level of Involvement

 
"In my experience, anesthesia coders are very concerned about using the correct modifiers for reporting personally performed cases and medical direction or supervision of CRNAs," Dennis says. HCPCS 2001 lists these common modifiers defining the anesthesiologist's and/or CRNA's level of involvement with anesthesia administration:
 
-AA -- anesthesia services performed personally by anesthesiologist. Use of this modifier requires that the physician be present for the entire anesthesia procedure, from the preanesthesia evaluation through postanesthesia. "In summary," Groudine says, "the anesthesiologist did the entire case himself." This modifier should not be used by CNRAs.
 
-AD -- medical supervision by a physician; more than four concurrent anesthesia procedures. Dennis' group uses this modifier infrequently, but she suggests that coders report it if it is appropriate. Groudine adds, "As supervision results in a lower reimbursement, medical direction should be billed whenever possible. However, the seven rules required for medical direction (box below) must be met."
 
-QK -- medical direction of two, three, or four concurrent anesthesia procedures involving qualified individuals. "When using -QK, make sure all aspects of the medical direction are documented," Groudine advises.
 
-QX -- CRNA service: with medical direction by a physician. This modifier indicates that a CRNA performed the service under the medical direction of an anesthesiologist who might be covering more than one room. "This modifier also lets the carrier know that there may be up to four concurrent bills from the directing anesthesiologist who uses modifier -QK to indicate medical direction," Groudine says.
 
-QY -- medical direction of one certified registered nurse anesthetist (CRNA) by an anesthesiologist. The modifier should be used if the anesthesiologist is directing only one case and not providing concurrent services.
 
-QZ -- CRNA service: without medical direction by a physician. Dennis feels that modifier -QZ is ambiguous. "Some practices have been advised by their carriers to use this code if they don't meet the seven rules required for medical direction," Dennis says. "It is not always easy for coders to ensure that all the criteria for medical direction have been met. Our coders construct careful time lines to try to determine if the anesthesiologist meets the criteria. If the criteria are not met, we append modifier -QZ. I would advise coders to call their carrier for instructions on using -QZ."

 
Groudine says modifier -QZ has risks: "Many hospital bylaws require anesthesia supervision. Billing Medicare as if no anesthesiologist was involved in the care when in fact he or she was, could result in a violation of hospital policy -- which might have serious legal ramifications. Further, many Medicare payers reimburse anesthesiology services with modifier -QZ at a higher rate than those with modifier -AD. It is conceivable, then, that some carriers might construe the use of -QZ as Medicare abuse by providers looking to increase their revenues."
 
Regarding documentation, Dennis says they do not routinely include medical records with claims unless the procedure is unlisted, multiple procedures are performed the same day, or for workers' compensation claims.
 
Hecht states that the commercial carriers her association deals with rarely require the use of modifiers and may (through their computer processing systems) automatically assign modifiers to claims. Hecht says, "Our coders have learned to be on the lookout for payer-assigned modifiers which can impact our reimbursement or even alter the description of services we performed."  
 
Dennis concludes, "Unfortunately, there are no hard and fast rules regarding the use of modifiers. Sometimes we only learn what carriers want by trial and error. As coders and billers, make yourself familiar with the processing policies of your local Medicare and private insurers. And, make sure that all of your billing tools, such as CPT, ICD-9, and CCI, are up-to-date."