Anesthesia Coding Alert

Teach providers that payment for 2 more units depends on their documentation.

Coder and providers are always looking for ways to legitimately increase their practice’s income through add-ons such as qualifying circumstances codes. Don’t jump too soon, however, when your provider marks “emergency” on a report. The extra two units you could receive for +99140 (Anesthesia complicated by emergency conditions [specify] [List separately in addition to code for primary anesthesia procedure]) might be justified, but check these areas first.

Know the Correct Definition of ‘Emergency’

CPT^® and the ASA Relative Value Guide agree on what constitutes an emergency. Guidelines in both resources state that “an emergency is defined as existing when delay in treatment of the patient would lead to a significant increase in the threat to life or body parts.”

Pitfall: The anesthesia provider might mark “emergency” on his paperwork, but not include details of what makes the case an emergency. As with everything related to coding, you need supporting documentation to explain the emergency conditions.

Solution: If there’s a real reason to report an emergency (such as a ruptured appendix, 540.0), your physician should clearly document the reason. Another diagnosis code to indicate a problem (such as unstable angina, 411.1) could help show the payer you’re reporting an unusual situation. The second diagnosis can also help in an appeal if a payer that ordinarily recognizes +99140 denies the claim.

“There often are clues to an emergency situation in the documentation, such as a work-related emergency or an accident,” says Kelly Dennis, MBA, ACS-AN, CANPC, CHCA, CPC, CPC-I, owner of Perfect Office Solutions in Leesburg, Fla.

Don’t Assume ED Equals Emergency

Most patients who are admitted to the hospital through the Emergency Department (ED) are experiencing emergency situations – but not everyone is.

Example: Just because a mom-to-be enters the hospital through the ED or needs a cesarean delivery doesn’t make her case an emergency. Circumstances such as fetal distress or prolapsed cord, however, nearly always imply an emergency that needs immediate attention. Under those circumstances, you could justify reporting +99140 with a diagnosis showing that the delivery was not routine, such as any from the 661.xx (Abnormality of forces of labor) code family. Any other diagnoses explaining the reason for special care should also be part of your claim.

Ignore the Timing

Some physicians believe that unexpected events – especially those that occur after normal business hours or on weekends – qualify as emergencies. That’s not the case, according to the emergency definition in CPT^® and the Relative Value Guide that doesn’t mention the time of service.

Tip: When considering whether to report +99140, always ask yourself whether delaying treatment would have led to a significant increase in risk to the patient’s life or limb. If not (or if you don’t have enough documentation to support that claim), don’t submit +99140.

Example: An 80-year-old man is admitted to the hospital late Saturday evening with a hip fracture. The cardiologist won’t clear the patient for surgery until he has an echocardiogram the next day. Delaying surgery because of the echocardiogram doesn’t constitute an emergency.

Get Familiar With Payer Guidelines

Some payers recognize qualifying circumstances codes such as +99140, but others don’t. Keep these tips in mind as you navigate claims with different payers:

• Always discuss qualifying circumstances when you're negotiating contracts.
• Include a contractual clause stating whether your specific payer reimburses based on the ASA RVG. That way you can provide a copy of the RVG page and remind the representative of your contract in case you receive a denial.
• If you receive a denial for +99140, when you appeal include the RVG page or CPT^® guidelines stating that an emergency is separately billable.
• Always know how your payers handle qualifying circumstances. “In some states, Medicaid will cover qualifying circumstances,” Dennis says. “For example, Indiana Medicaid will pay for two units, but you should only report one unit. Other states, such as Florida, don’t have additional payments for qualifying circumstances. Check your state’s Medicaid policy regarding payment and reporting rules.”

Remember: Payers won’t reimburse — or they may pay at a lower rate — based on their perception of how others in the same specialty are performing. If no one bills for a service, such as +99140, eventually the carrier will no longer allow the particular code. If billing continues for the procedure, however, carriers will see the procedure as a viable and billable service and may consider allowing it.

“Not all payers publish rules or coding information for anesthesia,” Dennis notes. “If you don’t report codes, the payer can’t even consider payment. So if you’re unsure whether the service is payable, always report it just in case.”