Anesthesia Coding Alert

Tip: Medicare doesn't reimburse, but other payers still might.

Traditional Medicare plans never cover qualifying circumstances (QC) codes +99100-+99140, but that doesn't mean you should steer clear of reporting them to other payers. Read on for three areas to watch before adding any QC codes to your claims:

+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)

+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).

Watch your non-Medicare payers' definitions for +99100, advises Tacy Brown of Mountain West Anesthesia in Salt Lake City, because they might interpret "older than 70" differently. "Some payers assume the patient must be 71 years of age to be 'older than 70' and some define it as being past the seventieth birthday," Brown says.

Verify Your Payer's QC Stance

Check the most recent guidelines when dealing with non-Medicare payers. When it comes to reimbursing QC codes, "other insurance companies vary," says Kelly Dennis, MBA, ACS-AN, CAN-PC, CHCA, CPC, CPC-I, president of Perfect Office Solutions in Leesburg, Fla. "And some pay more than the ASA suggested relative base value."

Example: In Alabama, BCBS policy states that it may allow up to five base units for certain qualifying circumstances, such as +99116. Payers might set higher base units than the ASA's recommended values for the same services.

Your actual reimbursement depends on your contracted rate. For example, your local payer might reimburse four units for a QC code that the ASA lists with a base value of two. If you have a contract rate of $40 per unit, for instance, being paid for two additional units (according to your payer's contract rate) adds $80 to your pocket.

Even if some payers don't recognize the QC codes or don't pay more than the ASA recommended values, you're wise to learn which ones do. "Even if you deserve the extra reimbursement, they won't pay it if you don't bill it," Dennis points out. "Your missed opportunity for billing is 100 percent if you aren't reporting to any carriers."

Use QC With -- Not in Place of -- P Modifiers

Physical status modifiers help the insurer understand potential risks your anesthesia provider considered because of the patient's health status during the procedure. Qualifying circumstances codes address complicating factors that can affect how your anesthesiologist cares for a patient. Although the P modifiers and QC codes might cross into similar territory, reporting one doesn't cancel out the other.

Example: Your provider administers anesthesia during a hypertensive patient's surgery. The physicians classify her hypertension as "severe," so qualifies her for physical status modifier P3 (A patient with severe systemic disease). The anesthesiologist uses controlled hypotension during the procedure, so you could report +99135 in conjunction with the appropriate anesthesia code.

Bonus codes: You can include more than one QC code on your claim. For example, an 11-month old infant has emergency surgery for third degree burns covering less than 4 percent of the total body surface area (TBSA). Begin your claim with 01951 (Anesthesia for second- and third-degree burn excision or debridement with or without skin grafting, any site, for total body surface area [TBSA] treated during anesthesia and surgery; less than 4% total body surface area), which carries a base value of 3. You can add +99100 to the claim because 01951 does not take age into consideration; also include +99140 because of the emergency conditions.

Double Check Against Code Descriptors

Most anesthesia codes have wide-reaching descriptors to cover many situations, but a few fit more specific circumstances.Such is the case with four codes designed for young children:

00326 -- Anesthesia for all procedures on the larynx and trachea in children younger than 1 year of age

00561 -- Anesthesia for procedures on heart, pericardial sac, and great vessels of chest; with pump oxygenator, younger than 1 year of age

00834 -- Anesthesia for hernia repairs in the lower abdomen not otherwise specified, younger than 1 year of age

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.

Translation: Because these four codes specify the patient's age, the associated base values already include the risk of caring for a young child. When you code for these types of procedures, report the applicable CPT procedure code instead of QC code +99100. If other extraordinary circumstances apply, however, Brown says you can bill other QC codes with agebased codes 00326, 00561, 00834, or 00836. For example, you could report +99140 if your provider administers anesthesia under emergency conditions.

"Documentation must support the circumstances being reported," Dennis adds. "In this example, you're coding for an emergency so the documentation should support an emergency condition."

Bottom line: "You have to be especially careful with Medicaid programs because each individual state is unique," Brown says. For example, Medicaid of Nevada does not allow reimbursement for QC codes or P modifiers. Utah Medicaid, by contrast, reimburses P modifiers but not QC codes. Learn what your payers reimburse -- and how much -- so you can verify clean claims and appropriate payments.