Anesthesia Coding Alert

Hint: Modifiers can show payers which anesthesia professional performed a service.

Getting paid correctly with anesthesia modifiers may not be as easy as you think! If you’ve read the Codify articles for filing clean certified registered nurse anesthetist (CRNA) claims, you know anesthesia has special modifiers that affect payment for services based on the type of provider. In this article, we will dig just a little bit deeper to uncover anesthesia modifier usage in various situations and with different payers.

Understand How Modifiers Describe Anesthesia Services

For anesthesia services, there are multiple providers and different ways anesthesia services are provided. While one would hope that a physician specifically trained in anesthesia is required to report anesthesia modifiers, that is not always the case. There are payers that allow non-anesthesiologist physicians to report certain types of anesthesia, and a modifier that identifies a surgeon providing anesthesia. CRNAs and certified anesthesia assistants (CAAs) both work in conjunction with an anesthesia care team, although only certain modifiers apply to each. CRNAs and CAAs are qualified individuals (QI) and nonphysician anesthetists, even if they have a doctorate degree.

We will start with modifiers that identify the provider and discuss some of the reasons why coders break the modifier rules. Modifiers have a pecking order for most payers, which is important to understand, as the correct order is necessary to ensure accurate payment. The sequencing of modifiers is true for any specialty, not just anesthesia. With anesthesia, the importance is that a major part of payment is associated with the first assigned “payment” modifiers, rather than supplemental, secondary, or tertiary informational or statistical modifiers. Although modifiers are defined (and if you look closely, you will see the definitions are similar but not word-for-word), modifier rules are not clearly outlined in the CPT ^®  or HCPCS^® code books, or the American Society of Anesthesiologists (ASA) Relative Value Guide (RVG^®). In addition, payers have their own rules and requirements, which makes it tough for new coders. You can find more information on the difference between payment and informational modifiers in AAPC’s article What are Medical Coding Modifiers?.

The ASA’s RVG is a very helpful resource, but not all anesthesia coders have access to either a RVG or HCPCS, so availability to the internet is a valuable tool when looking for Level II HCPCS codes not listed in the CPT^®. Table I includes primary payment modifiers required by Medicare in all states to identify the provider of anesthesia services:

Table I

Payment for the modifiers listed in the table will vary depending on the payer, and possibly on the state. While Medicare allows either 100 percent payment of the Medicare Physician Fee Schedule (MPFS) to a CRNA or personally performing physician — or a 50/50 split of payment between physicians and nonphysicians for anesthesia services — other payers may reduce payment. According to a recent Becker’s Clinical Leadership article, Anthem and Cigna pay less for modifier QZ (CRNA service without medical direction by a physician) claims than Medicare. Ohio’s Medical Mutual will begin reducing payment in January. While Kaiser Foundation Health Plan reversed its intended policy to do the same, it now requires primary payment modifiers for anesthesia.

Typically, the second-position modifier will identify extraordinary circumstances that make the patient’s anesthesia care more difficult. Physical status modifiers have been in use for over 60 years and are published by the ASA as indicators of a patient’s current health status. The anesthesia pre-assessment includes a physical status for each patient, as recommended by governance of the ASA. Neither a healthy patient or a patient with a mild systemic disease qualify for additional payment. However, those patients with severe systemic diseases — patients with conditions that are a constant threat to life — and patients who may not survive the operation are difficult to treat and require greater care. The conditions are described but not limited to comorbidities. While Medicare bundles physical status modifiers, presumably to save money, commercial payers, workers’ compensation, and many Medicaid plans recognize these modifiers for additional payment. Unfortunately, commercial payers are also trying to chip away payment for these difficult anesthesia patients, but the ASA is working to help these payers understand the additional care needed and has asked for assistance from anesthesia practices in identifying payers implementing policy changes to exclude payment for physical status modifiers. See more information in this ASA table:

Table II

Examine This Example of Informational and Statistical Modifiers

An informational or statistical modifier is reported after all payment modifiers are appended.  Medicare and other payers have policies related to monitored anesthesia care (MAC), which are identified by specific modifiers. Often, these modifiers are built into software parameters to drop automatically based on type of anesthesia and payer requirements. However, without coder or data entry intervention, there are some modifiers that may not be picked up based on the patient-specific information, which isn’t typically entered into the software system. Palmetto GBA Jurisdiction J, which covers providers in Alabama, Georgia, and Tennessee, requires modifiers to identify either MAC; MAC for procedures that are deep, complex, complicated, or invasive; or MAC for patients with severe cardiopulmonary conditions. Although the payment amount is not affected by these modifiers, Local Coverage Determinations (LCDs) define the circumstances and modifiers required to ensure that anesthesia services are medically necessary. If a Palmetto GBA patient has a diagnosis of congestive heart failure (CHF) and has MAC for a procedure, they qualify for a G9 modifier instead of a QS as indicated in Table III below:

Table III

Unless the parameters tie a diagnosis code to the type of anesthesia, a QS (MAC service) modifier may drop instead of a G9 (MAC for patient who has a severe cardio-pulmonary condition) mdifier. It is not the end of the world, since a MAC modifier is being reported; however, payers expect accuracy and G9 is the accurate modifier for this payer. It is important to pay attention to payer policies, though, as not all payers recognize the same payment or informational/statistical modifiers. For example, reporting any modifiers other than a 78 (Unplanned return to the operating room, related procedure), QK (Physician supervision of anesthesia) or QS (MAC service) to Florida Medicaid will cause a claim rejection.

One can see how important it is to append the correct modifier in the correct position to the correct payer. If you keep the mindset that you will always be learning, you are on the right track!  

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