Use This Advice to Code and Bill Qualifying Circumstances for Anesthesia
Remember: Qualifying circumstances codes are never a primary anesthesia code. Qualifying circumstances affect the ways and timing of anesthetists provide anesthesia, so it makes sense that they also affect the reporting and billing of the services. Here’s what you need to know about spotting and defining qualifying circumstances, as well as tips on reporting and billing these anesthesia services. Look to These Codes for Qualifying Circumstances The CPT® guidelines for anesthesia services say: “Many anesthesia services are provided under particularly difficult circumstances, depending on factors such as extraordinary condition of patient, notable operative conditions, and/or unusual risk factors. This section includes a list of important qualifying circumstances that significantly affect the character of the anesthesia service provided. These procedures would not be reported alone but would be reported as additional procedure numbers qualifying an anesthesia procedure or service.” According to the CPT® code book and the American Society of Anesthesiologists (ASA) Relative Value Guide® (RVG®), there are four codes that can be billed for qualifying circumstances in anesthesia. These add-on codes are: The RVG® notes that each of these should be listed separately in addition to the code for the primary anesthesia procedure; never report qualifying circumstances codes alone. The RVG® does have a comment on these codes as well. You should not report 99100 with 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), or 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). These codes are already age-based and therefore do not need an additional qualifying circumstances code. You should not report 99116 or 99135 in conjunction with 00562 (Anesthesia for procedures on heart, pericardial sac, and great vessels of chest; with pump oxygenator, age 1 year or older, for all noncoronary bypass procedures or for re-operation for coronary bypass more than 1 month after original operation), 00563 (Anesthesia for procedures on heart, pericardial sac, and great vessels of chest; with pump oxygenator, age 1 year or older, for all coronary artery bypass grafting procedures), or 00567 (Anesthesia for direct coronary artery bypass grafting; with pump oxygenator). Hypothermia or hypotension may be the result of being on a cardiopulmonary bypass, so it is not necessary to bill separately. Check on Respective Reimbursement Rules Commercial payers should reimburse additional units for these qualifying circumstances codes, and each code has a base unit value attached, according to the RVG®: Qualifying Circumstances Code Base Unit Value 99100 1 99116 5 99135 5 99140 2 While this seems straightforward, it is a great example of why it is so important to understand payer policies: Some payers do not consider these reimbursable codes. Much like the anesthesia physical status codes, which assess and describe a patient’s comorbidities and preoperative risk, the Centers for Medicare & Medicaid Services (CMS) does not recognize the qualifying circumstances codes. Even though CMS does not recognize these codes, many commercial payers do. Always check your payer policies and contracts for guidance on whether they consider these codes reimbursable or not. Check out These Examples Example 1 Coding: f (Anesthesia for intraperitoneal procedures in lower abdomen including laparoscopy; not otherwise specified) with base unit value of 6, plus 99100 with a base unit value of 1 If this same patient had Medicare as their primary payer, you would only report 00840 since Medicare does not recognize 99100. Example 2 Coding: Report 00790 (Anesthesia for intraperitoneal procedures in upper abdomen including laparoscopy; not otherwise specified) with a base value of 7, plus 99140 with a base value of 2. Because this patient’s payer recognizes the qualifying circumstances codes, 99140 is billable as documentation supports that this case met the CPT® definition of an emergency. Per CPT®, an emergency occurs when a delay in treatment of the patient would lead to a significant increase in the threat to life or body part. Not every case that is urgent or comes in through the emergency department (ED) would qualify for the additional emergency code. Documentation must support the definition of an emergency case as defined by CPT®. Example 3 Coding: Report 00216 (Anesthesia for intracranial procedures; vascular procedures) with a base unit value of 15. Also, report 36620 (Arterial catheterization or cannulation for sampling, monitoring or transfusion; percutaneous) for the arterial line. Because this patient has Medicare, codes 99116 and 99135 are not billable, even though total hypothermia and controlled hypotension were utilized during the case. If this patient had commercial insurance, these codes may be billable based on that specific payer’s policy regarding qualifying circumstances. Main takeaway: Qualifying circumstances codes can provide additional reimbursement for anesthesia services when specific clinical conditions are present, such as extreme age, emergency situations, or utilization of total body hypothermia and controlled hypotension. However, you should only report these codes when they are supported by CPT® guidelines and recognized by payer policies. While Medicare does not recognize these codes, many commercial payers do, making it essential to understand individual payer requirements. Accurate reporting of these codes helps ensure proper reimbursement and maintains coding compliance. Julie McDaniel, MHA, CPC, CANPC, Contributing Writer
Patient: 72-year-old female
Procedure: Appendectomy
Anesthesia type: General anesthesia
Insurance: Patient is still working, and has employer-provided insurance as primary (per the payer policy, it does recognize qualifying circumstances codes)
Patient: 35-year-old male
Procedure: Emergency splenectomy after motorcycle accident due to ruptured spleen
Anesthesia type: General anesthesia
Insurance: Employer-provided commercial insurance
Patient: 67-year-old male
Procedure: Craniotomy with clipping of cerebral aneurysm: Anesthesiologist utilizes total body hypothermia and controlled hypotension and places an arterial line
Anesthesia type: General anesthesia
Insurance: Medicare
