Anesthesia Coding Alert

Reimbursement:

Do You Know When an Emergency Leads to +99140?

Published on Thu Apr 07, 2022

Let these tips help guide your usage.

Appending qualifying circumstances (QC) codes to a claim can help further explain your anesthesiologist’s services and boost your reimbursement — if you report them correctly. Understanding how to use +99140 (Anesthesia complicated by emergency conditions (specify) (List separately in addition to code for primary anesthesia procedure)) can be especially tricky because of the “emergency” factor.

Read on for tips on what constitutes an emergency in this situation so your use of +99140 will have merit.

Understand What CPT^®Means by ‘Emergency’

People — and payers — can have varying definitions of 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.”

This means the provider cannot simply mark “emergency” on the chart. They need to include notes explaining what makes the case an emergency.

Tip: 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 detailed conversation with the anesthesiologist regarding the emergency anesthesia circumstances so that both are clear on the stipulations.

Remember ‘ER’ Doesn’t Automatically 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.

Here’s why: The provider might tend to define an emergency by the route the patient enters the hospital setting rather than the patient being in a life-threatening situation. Pregnant women typically come in through the emergency room but are triaged in the birthing ward. You might also see “emergency” on the chart if the patient has eaten within a specified amount of time. Although this presents an elevated risk from an anesthesia perspective, it does not automatically constitute an emergency.

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 O62.- (Abnormalities of forces of labor), O65.- (Obstructed labor due to maternal pelvic abnormality), or O66.- (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.

Plus: Fetal distress is another common emergency circumstance, and one that is more serious than some other conditions.

Know the Difference 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 +99140, the Relative Value Guide^®(RVGTM) from the American Society of Anesthesiologists (ASA) updated its description in 2019 to match the CPT^®definition. Now both resources define an emergency as “existing when delay in treatment of the patient would lead to a significant increase in the threat to life or body part.”

Tip: Talk to the anesthesiologist directly for a more thorough account of the encounter you are reporting to determine whether the encounter merits +99140. A patient who can’t breathe or who requires emergency intubation is an emergency, as is a mom-to-be whose baby moves into the breech position during labor. Either of those scenarios could lead to loss of life.

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,” says Kelly D. Dennis, MBA, ACS-AN, CANPC, CHCA, CPC, CPC-I, owner of Perfect Office Solutions in Leesburg, Florida. “It’s not the same as when a person has a broken finger in the emergency room and may require some sort of sedation to keep still during a reduction or manipulation.”

Get Familiar With 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 nongovernment payers.

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

For example, United Healthcare policy 2021R0032C states the insurer will pay two units for +99140. Check with individual payers to verify what their reimbursement might be.

Tip: Include a contractual clause stating whether your specific payer reimburses based on the ASA RVGTM. That way you can provide a copy of the RVGTM 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.”