Anesthesia Coding Alert

Hint: Don’t expect consistency across different payers’ policies.

Anesthesia coders often improve their coding by making mistakes, which is a perfectly valid way to learn when you cannot find policies and receive conflicting information from other coders when asking questions.

There is also a reason for conflicting information: Payer rules vary by payer and by geographical location. Take modifier 22 (Increased procedural services), for example. Coders have a description of the code from coding resources, but what does it mean to the payers, and which ones will recognize for additional payment for anesthesia? To get to the answers, coders need to take a deep dive into a few different resources.

Understand Modifier 22 Do’s and Don’ts

Modifier 22, even with additional comments indicating “When the work required to provide a service is substantially greater than typically required,” seems straightforward. However, the description doesn’t point to a particular specialty, although it does exclude evaluation and management (E/M) services. Coders can also find additional information in Chapter 1 of the current National Correct Coding Initiative (NCCI) Policy Manual, identifying this modifier as “NCCI PTP-associated.” PTP indicates procedure-to-procedure and explains edits are “based on services provided by the same physician to the same beneficiary on the same date of service.”

So far, not a problem: same patient, same beneficiary, and same service date are the types of services anesthesia providers typically report on claims. However, there is a catch for Medicare, as modifier 22 does not bypass an NCCI PTP edit, and Medicare Administrative Contractors (MACs) such as Noridian do not include modifier 22 in their list of anesthesia modifiers.

Check With Your Respective MAC

Noridian’s policy does, however, provide important clues to explain “Pricing modifiers must be placed in the first modifier field” and “Informational modifiers are used in conjunction with pricing modifiers and must be placed in the second modifier position.”

We can learn from this MAC that:

1) Modifier 22 is not a covered modifier for anesthesia services;

2) There is a pecking order for modifiers; and

3) Physical status modifiers are not used by Medicare (off topic for the modifier 22 discussion, but still valuable information).

Coders could also learn this by reporting anesthesia claims to their MAC with modifier 22 and receiving a denial.

Beware: A denial based on reporting physical status (PS) modifiers may vary by location and depend upon your respective MAC’s determinations.

MACS may deny anesthesia services reported with modifier 22 even though the American Society of Anesthesiologists (ASA) recommends using modifier 22 to report “field avoidance” and “limited access to the patient’s airway.”

The ASA published several Timely Topics in Payment and Practice Management articles in 2019 to further explain the use of modifier 22 for anesthesia services. Prior to 2019, the Relative Value Guide^® (RVG) described field avoidance as follows: “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 Base Value of 5 regardless of any lesser base value assigned to such procedure in the body of the Relative Value Guide.”

In 2019, the RVG comments were updated to remove positioning and describe field avoidance as “Whenever access to the airway is limited.” Many of the procedures that require unusual positioning are already valued at 5 units, and the ASA stipulation outlined in the description for reporting modifier 22 is related to anesthesia procedures that have 3 or 4 base units. This can be confusing for coders and payers — so what about commercial payers?

Know the Nitty-Gritty Details for Each Specific Payer

This is where coders will come to a fork in the road! As examples, we will look at some payers who recognize modifier 22 for anesthesia services, and payers who do not recognize the modifier for anesthesia services. Starting with payers who recognize modifier 22 for anesthesia services, United Healthcare’s (UHC’s) anesthesia policy includes a description that “Only anesthesia services with a Base Unit Value less than 5 units, appended with modifier 22 for unusual positioning and field avoidance, would be considered for additional reimbursement when submitted with supporting documentation.” UHC policy includes “adding additional base units so that the total base units =5,” although they do not indicate whether the provider will manually override the unit value or whether UHC will override the unit value.

For example, Blue Cross Blue Shield (BCBS) of Oklahoma will allow payment, as long as documentation supports the service and the base unit for the anesthesia procedure is less than 5 — although this policy still relies on the information published by the ASA prior to 2019 regarding field avoidance and patient positioning. However, they offer sound advice for documentation: “Report should be detailed and specify how the procedure was more complex than usual and also quantify how much more complex the procedure was as compared to the usual. A brief letter or statement that is not a part of the medical record is not sufficient to justify the use of modifier 22.”

Priority Health, a Michigan plan that may include Medicaid patients, has a very liberal policy that allows anesthesia to report when multiple factors apply, including, but not limited to, extreme obesity, comorbidities, trauma, or excessive blood loss. This is not a guarantee of payment, as each procedure reported with modifier 22 requires a review and “additional reimbursement will be considered only when the documentation submitted clearly states the exceptional nature of the service provided.”

On the other hand, although Florida Medicaid does not mention modifier 22 in their anesthesia policy, which was last updated in June 2016, they only pay three modifiers for anesthesia services: 78 (Unplanned Return to the Operating/Procedure Room by the Same Physician or Other Qualified Health Care Professional Following Initial Procedure for a Related Procedure During the Postoperative Period), QK (Medical direction of two, three, or four concurrent anesthesia procedures involving qualified individuals), and QX (Crna service: with medical direction by a physician).

As a result, any anesthesia claims sent with modifier 22 or any other modifiers for anesthesia services will be denied. Since February 2022, Premera BCBS, located primarily in Washington and Alaska, specifically excluded anesthesia from reporting modifier 22 and explains: “For increased anesthesia service, additional time units or physical status modifiers to identify that additional work was required to render the anesthesia service should be billed instead of modifier 22.”

As one can see, commercial and Medicaid payers can vary greatly, so coders will need to check local policies. Coders must also look for the most up-to-date policies; as noted above, not all payers keep up with the description changes published by the ASA. When applicable, ensure the procedure code reported with modifier 22 has a base value of less than 5 units, and that documentation supports more than just a mere mention of difficulty or field avoidance.

Kelly D. Dennis, MBA, ACS-AN, CANPC, CHCA, CPMA, CPC, CPC-I