Anesthesia Coding Alert

Question: I know Medicare Part B does not reimburse for extenuating circumstances, but some private carriers do. Should I still include the extenuating circumstances codes on the claim so Medicare can deny payment and we can bill the secondary carrier? Is there a HCPCS modifier to indicate that we-re only billing to Medicare to receive a denial?


Wisconsin Subscriber

Answer: You-re correct that Medicare does not pay for extenuating (or qualifying) circumstances codes, such as +99100 (Anesthesia for patient of extreme age, under 1 year and over 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]) and +99140 (Anesthesia complicated by emergency conditions [specify] [list separately in addition to code for primary anesthesia procedure]).

Two HCPCS modifiers represent unpaid or non-covered services: GY (Item or service statutorily excluded or does not meet the definition of any Medicare benefit) and GZ (Item or service expected to be denied as not reasonable and necessary). Whether you submit your claim with these modifiers depends on the carriers involved with the case.

Some coders recommend that you include modifier GY or GZ on the Medicare claim, but remove the modifier before sending the claim to the secondary carrier. Other coders believe the modifier is unnecessary because Medicare realizes you must sometimes report services you know Medicare won't reimburse.

Your best tactic is to know the secondary carrier's policy regarding these services. Some private carriers will only reimburse for services if Medicare does not, but other carriers will reimburse regardless of Medicare's stance.