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Don't Automatically Cross Off Qualifying Circumstance Claims
Anesthesia & Pain Management Coding Alert 2008: Volume 10, Number 9
Digging for buried reimbursement treasure pays off
You often see Medicare held up as the gold standard for coverage -- not to mention reimbursement. But you don't want to miss the hidden value in looking beyond Medicare for patients with other insurers.
One situation where you may find some surprising -- and potentially profitable -- answers is qualifying circumstances. Let our experts tell you how to approach these add-on codes and why some extra legwork can lead to more reimbursement for you.
Understand Special Qualifying Circumstances
CPT has four add-on codes to describe qualifying circumstances (QC). These cover complicating factors that can change how your anesthesiologist cares for a patient:
+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).
Tip: Don't use these QC codes to replace physical status modifiers when you report complicating conditions. According to the CPT anesthesia guidelines, you should use these add-on codes to describe other conditions that "significantly affect the character of the anesthesia service."
Keep in mind: You can use more than one QC add-on code if your case has multiple applicable circumstances.
Also, as with all add-on codes, you should never report QC codes without the primary anesthesia procedure code.
Pediatric QC Code Merits Extra Attention
You should be cautious when using the "younger than 1 year" add-on code 99100 because payers include the risk of caring for a young child in the base value of many primary codes intended for young children.
Anesthesia codes designated for young children that you shouldn't report with 99100 include the following:
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.
Master Hypothermia, CABG Anesthesia Coding
Bundle up: When your anesthesiologist performs routine hypothermia for coronary artery bypass graft (CABG), traumatic brain injury, cerebral aneurysm or other neurological problems, you shouldn't report 99116 if your anesthesia code description already implies hypothermia.
For example: Your anesthesiologist uses a pump oxygenator to accomplish hypothermia and rewarming following a CABG procedure on a patient younger than 1 year of age.
How to code it: You'll report 00561 (Anesthesia for procedures on heart, pericardial sac, and great vessels of chest; with pump oxygenator, younger than 1 year of age) and 00562 (… with pump oxygenator).
Also worth noting: Use 00563 (… with pump oxygenator with hypothermic circulatory arrest) when reporting deep hypothermic circulatory arrest (DHCA) that halts blood circulation performed with CABG.
Warning: Hypothermia is bundled with 00561-00566, so you won't report these codes with 99116. Because hypothermia promotes cardiac arrhythmia and anesthesiologists wouldn't perform this off pump, pump oxygenator codes 00561-00563 are the most important for you to watch for.
Know Who Will Pay When Medicare Won't
Reality: "Qualifying circumstances are never covered by Medicare in any state," says anesthesiology coding expert Kelly Dennis, MBA, CPC, ACS-AP, with Perfect Office Solutions of Leesburg, Fla. "Other insurance companies vary. And some pay more than the ASA suggested relative base value."
She says that Medicaid and Blue Shield will reimburse for QC in some states, while they won't pay in others. In Alabama, for example, BCBS policy states that it may allow up to four base units for certain emergency anesthesia services such as 99140, while the ASA recommended value is two units, Dennis says.
What this equates to in reimbursement dollars depends on your contracted rate. Dennis says, "If the rate was $40 per unit, it means an additional $80 in reimbursement -- and they won't pay it if you don't bill it."
Bottom line: "I've often told people who ask that their missed opportunity for billing is 100 percent if they aren't reporting to any carriers," Dennis says.
Don't miss: "Medicaid will pay for QC depending on the state," says Debbie Farmer, CPC, ACS-AN, coder with Auditing for Compliance & Education in Leawood, Kan. But "I have seen that they do not allow the unit rate that is recommended in the Relative Value Guide."
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