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Field Avoidance and Special Positioning

Follow coverage rules for correct coding of these unique anesthesia circumstances.

by Kelly Dennis, MBA, CPC, CPC-I, CANPC, ACS-AN, CHCA
Qualifying circumstances, including special positioning and field avoidance, are unique to anesthesia services and require a bit of “insider knowledge” to code properly.
Sometimes Surgery Requires Unique Positions 
The supine position — when the patient lies with back flat — is the most common surgical position, and usually the safest. Special positioning, however, may be necessary to prevent “end organ damage due to hypoxia or hypotension to direct nerve injury due to compression or traction,” according to Sarah Gerken, MD (American Association of Orthopaedic Surgeons, “Preventing Positioning Injuries: An Anesthesiologist’s Perspectives”).
Gerken continues:

Patients at increased risk of positioning injuries, specifically peripheral nerve injury, include obese patients and those with diabetes, peripheral vascular disease, hereditary peripheral neuropathy, or an anatomic variable (eg, cervical rib). Thin patients may also have an increased risk of sustaining peripheral nerve injury during surgery.

“Field avoidance” means the anesthesia provider does not have access to the patient’s airway during surgery. This may be due to the nature of the case (e.g., face or shoulder surgery) or the surgical position of the patient.
Check Guidelines and Base Value Units
Although not specifically mentioned in the minimal Anesthesia guidelines found in the CPT® codebook, field avoidance and special positioning may be considered services under the Special Report section. Both field avoidance and unusual positioning raise risk for the patient and anesthesia provider. These unique circumstances have a minimum base value of five, per the American Society of Anesthesiologists® (ASA):
Any procedure around the head, neck, or shoulder girdle, requiring field avoidance, or any procedure requiring a position other than supine or lithotomy, has a minimum Base Value of 5, regardless of any lesser base value assigned to such procedure in the body of the Relative Value Guide®.
Note: The fee schedule amount for physician anesthesia services is based on allowable base and time units multiplied by an anesthesia conversion factor specific to that locality. The base unit for each anesthesia procedure is listed in the HCPCS file that the Centers for Medicare & Medicaid Services (CMS) releases annually.
A minimum base value of five units automatically excludes reporting special positioning and field avoidance with many anesthesia services. But because there are over 80 anesthesia codes with a base value of fewer than five units, there is a good chance your anesthesia providers will qualify for additional payment for some of the field avoidance and special positioning — if documentation supports the reported circumstances.
If a surgery is performed in either the supine (patient is lying on his or her back) or lithotomy (patient is on his or her back with the hips and knees flexed and the thighs apart) position, you may not report special positioning.
When determining whether to report special positioning, remember to check if the anesthesia base value is fewer than five units, and consider the documented patient position, particularly if the patient is morbidly obese (according to “Anesthesia & Pain Coder’s Pink Sheet,” a study of positioning found that the reverse Trendelenberg was the optimal position for morbidly obese patients).
For example, if a patient has a closed procedure on his or her elbow, report ASA code 01730 Anesthesia for all closed procedures on humerus and elbow (base value, 3 units). If the anesthesia provider documents the patient was in the prone position, you may report this procedure as a special position to capture two additional units.
Reporting Rules Vary 
Qualifying circumstances, including field avoidance and special positioning, are not covered by CMS — although these exclusions are not mentioned in the Payment for Anesthesiology Services section of the Medicare Claims Processing Manual, Pub. 100-04, Chapter 12 – Physicians/Non-physician Practitioners (Section 50). If you consider that other anesthesia qualifying circumstances (e.g., CPT® 99100 Anesthesia for patient of extreme age, younger than 1 year and older than 70) have a B or bundled status with anesthesia services, Medicare nonpayment for field avoidance and special positioning is not surprising. CGS Administrators, LLC, includes anesthesia qualifying circumstances under Status B codes in the publication “Bundled, Inactive and Non-Payable Codes for 2014: Medicare Physician Fee Schedule Data Base”:

  • Payment for these services is always included in payment for other services not specified. There are no RVUs (Relative Value Units) or payment amounts for these codes, and separate payment is not made.
  • As an added difficulty, there are no specific procedure codes or modifiers to describe field avoidance and special positioning.

Although traditional Medicare does not cover qualifying circumstances, this is not always true for Medicare Replacement Plans or Medicaid programs, which vary by state. For example, the Medicaid carrier for California, Medi-Cal, allows additional payment for anesthesia procedures complicated by unusual position or surgical field avoidance when identified with modifier 22 Increased procedural service to indicate increased procedural services.
Commercial insurance policies often recognize the value of special positioning and field avoidance, although the reporting processes may differ. Hawaii Medical Service Association© (HMSA), an independent licensee of Blue Cross and Blue Shield (BCBS), requires the use of modifier 23 Unusual anesthesia, and specifies, it “should be used to indicate anesthesia services complicated by procedures performed in the prone position or by field avoidance.”
Specific anesthesia policy and anesthesia billing rules are often non-existent or difficult to find. If carrier policy does not define whether qualifying circumstances are covered, they should be billed and reported. Unless otherwise specified, you may report either special positioning or field avoidance circumstances with modifier 22, and “field avoidance” or “xxx position” in box 19 or the electronic equivalent.
If an appeal is necessary, help an insurance company understand the value of the service by explaining why it is medically necessary.
Documentation Always Matters
Remember the adage, “If it wasn’t documented, it wasn’t done.” You cannot capture billable services that are not indicated on the anesthesia record, even if they are marked on an internal billing sheet. Anesthesia providers must understand that qualifying services may be missed if they are not clearly documented, and you should understand when these services might be performed and how they are documented.
Billing sheets are not usually considered part of the patient’s medical records. There isn’t a universal anesthesia record and a typical anesthesia billing company seeing many different records; you must determine where on each record anesthesia providers document or describe these circumstances. This can be quite challenging with paper records and handwritten notes.
It’s also difficult if the anesthesia providers are using stick figures to draw the patient’s position on a paper anesthesia record. Sometimes, you can’t tell whether the patient is on his or her back (supine) or stomach (prone). With a paper record, the clearest way to document is a legible note in the remarks or comments section.
Electronic anesthesia records (EARs) are much easier to read, and may have a field summary that includes an area to document qualifying circumstances. If the EAR doesn’t have a field summary, look within the body or comments section.
If you don’t already know, learn where your providers document qualifying circumstances information.
HMSA: www.hmsa.com/PORTAL/PROVIDER/zav_pel.ph.ANE.900.htm
CGS Administrators, LLC, Bundled, Inactive and Non-Payable Codes for 2014:
Medicare Claims Processing Manual, Pub. 100-04, Chapter 12 – Physicians/Nonphysician Practitioners:

Kelly Dennis, MBA, CPC, CPC-I, CANPC, ACS-AN, CHCA, has more than 31 years’ experience in anesthesia coding and billing and speaks about anesthesia issues nationally. She has a master’s degree in Business Administration and serves as lead anesthesia advisor for Board of Medical Specialty. Dennis has owned her own consulting company, Perfect Office Solutions, Inc., since November 2001. She is a past officer of the Leesburg, Florida, local chapter.

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Kelly Dennis, MBA, CANPC, CPC, CPC-I, CHCA, ACS-AN, has more than 33 years of experience in anesthesia coding and billing and speaks about anesthesia issues nationally. She has served as lead anesthesia advisor on the Board of Medical Specialty Coding and has owned her own consulting company since 2001. Dennis is a member of the Ocala, Fla., local chapter.

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