Anesthesia Coding Alert

Being able to include one of the qualifying circumstances (QC) codes with a claim could add base units to your total calculation and lead to higher reimbursement – if you do it correctly. Here’s what you need to know before submitting +99140 (Anesthesia complicated by emergency conditions [specify] [List separately in addition to code for primary anesthesia procedure]) in hopes of “emergency” pay.

Get Clear on the CPT^® Meaning of ‘Emergency’

The trickiest part of reporting +99140 is verifying that you’re truly coding for an emergency situation or condition. According to CPT^® notes, “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.”

Problem: “I find that quite a number of cases come in where the anesthesiologist marks off ‘emergency’ but neglects to include what makes the case an emergency,” says coding educator Leslie Johnson, CCS-P, CPC.

Solution: The first step in clarifying +99140 use is to have an open dialogue with the anesthesiologist. The coder needs to sit down and have a heart-to-heart with the anesthesiologist regarding the emergency anesthesia circumstances so that both are clear on the stipulations.

Example: Johnson gives this hypothetical, but quite common, scenario. “There are times when a patient with abdominal pain will be found to have appendicitis, and is considered an emergency case, yet the patient was in observation or has been admitted for a time prior to the surgery,” she says.

Seeing ‘ER’ Doesn’t Always Mean Emergency

You’ll sometimes see an anesthesiologist report a case as an emergency because the patient was admitted via the emergency room (ER). But experts warn that you shouldn’t jump to coding conclusions.

Pregnancy can be a common example of this scenario, according to Johnson.

“They always want to define an emergency by the route the patient enters the hospital setting,” she says. “Typically, pregnant women come in through the ED, but they are triaged in the birthing ward. You might also see ‘Emergency’ on the chart if the patient has had food within a specified amount of time. True, this presents an elevated risk, but I’m not exactly sure if this constitutes an emergency and ASA has yet to define it.”

“Sometimes the anesthesiologist marks off ‘emergency’ on the record because of the route [the patient] entered into the hospital, not because it’s an actual life-threatening event which requires action at this particular moment,” Johnson says.

Instead: If there is a real reason for reporting an emergency, your physician should document that reason, and you should report a more descriptive diagnosis code telling the carrier that the situation was not routine. For example, any of the conditions under ICD-10 categories 062 (Abnormality of forces of labor), 065 (Obstructed labor due to maternal pelvic abnormality), or 066 (Other obstructed labor) could help support classifying a delivery as an emergency – not the fact that the mom-to-be was admitted through the ER.

“Fetal distress is another common emergency circumstance,” adds Kelly Dennis, CANPC, CHCA, CPC, CPC-I, owner of Perfect Office Solutions in Leesburg, Fla.

Draw the Line Between ‘Unexpected’ and ‘Emergency’

Some physicians maintain that unexpected events qualify as emergencies. For example, they might indicate “emergency” for any service provided after normal hours or on weekends. Remember, however, that the time of day doesn’t determine an emergency.

Definition: For the purposes of reporting code +99140, the RVG Guide defines an emergency as a situation when delaying a patient’s treatment would lead to a significant increase in the risk to the patient’s life or limb.

Best bet: Talk to the anesthesiologist directly for a more thorough account of the encounter you are reporting to determine whether the encounter merits 99140.

“It’s my understanding that any situation that may cause a loss of life or limb is considered an emergency,” Johnson says. “A patient who can’t breathe or who requires emergency intubation is an emergency. So is the woman who has breeched during her trial of labor and an emergency exists because such a thing could lead to loss of mother and/or baby.”

Another possibility: There are times when a patient presents, such as in respiratory distress or serious trauma, when there’s no time to gather all the data and anesthesia and/or intubation is necessary.

“These are true emergency situations where a lack of action could have serious consequences,” Johnson explains. “It’s not the same as when a person has a broken leg in the ED and may require some sort of sedation to keep still during a reduction or manipulation.”

Check Out Your Payer Guidelines

Knowing which payers recognize QC codes and reimburse accordingly can provide more than enough payoff. Because of that, always discuss qualifying circumstances when you negotiate contracts with Medicaid or non-government payers.

“Transitional Medicare does not pay, although there are quite a few Medicare reimbursement plans that will cover qualifying circumstances,” Dennis says.

Good idea: 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.

Experts note: 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 payer will no longer allow the particular code. If billing continues for the service, however, insurers will see it as a viable and billable service and may consider allowing reimbursement.

Caveat: As with many coding situations, there are exceptions to this coding rule. You should not automatically add QC codes to your claim when Medicare and Medicare-following carriers explicitly state that a specific code is not payable under any circumstances.

“It can still be a good idea to track the information, though,” Dennis advises. “Even though Medicare doesn’t pay, tracking can give practices a measure of how many emergency cases were seen during a time period.”