Medicare Vs. Primary Carrier Codes--Whose Do You Use?
Published on Wed Dec 01, 1999
Its not uncommon for patients to have more than one health insurance carrier to help make sure any medical conditions they have will be covered. This is especially true for older Americans, who often have Medicare as a secondary carrier. Filing claims and getting reimbursed for services can be quite an ordeal when multiple carriers are involved, but the reimbursement can get even trickier when the procedure codes accepted by one carrier are routinely denied by the other.
Donna Gullikson, coding and insurance supervisor with Medical Computer Business Services, a medical coding and billing firm in Augusta, GA., knows that the coding differences can be frustrating. There are so many differences between which carriers will reimburse for which codes, and even the same carriers guidelines may vary from one state to the other, she says.
For example, CPT Codes 1999 includes a series of physical status modifiers (P1-P6, as defined below) based on guidelines from the American Society of Anesthesiologists (ASA). No carrier in Massachusetts requires physical status modifiers, but other states do, says Joy Jacobson, director of reimbursement for the UMass Memorial Health Care Group Practice Plan in Worcester, MA., Most physicians try to capture the physical status modifiers anyway because of filing regulations other carriers may have. Thats why its always best to contact your local carrier before filing claims to find out which modifiers they require.
Medicare Denies, But
Other Carriers May Accept
Medicare and other carriers frequently update their lists of reimbursable procedure codes. Codes listed under the Qualifying Circumstances for Anesthesia section of CPT 1999 are not accepted by Medicare but may be accepted by commercial carriers. When using these codes for the carriers that accept them, each should be listed separately in addition to the code for the primary anesthesia procedure. They include:
99100Anesthesia for patient of extreme age, under
one year or over 70
99116Anesthesia complicated by utilization of total body hypothermia
99135Anesthesia complicated by utilization of controlled hypotension
99140Anesthesia complicated by emergency conditions (which must be specified). An emergency is defined as existing when a delay in treating the patient would lead to a significant increase in the threat to life or body part.
In addition, CPT 1999 states that all anesthesia services should be reported by using the five-digit anesthesia code for the procedure, as well as a physical status modifier that describes the patients state. These physical status modifiers are based on the ASAs ranking of patient physical status and are designed to distinguish among different levels of anesthesia services.
They are:
P1A normal healthy patient
P2A patient with mild systemic disease
P3A patient with severe systemic disease
P4A patient with severe systemic disease that is a constant threat to [...]
