Part B Insider (Multispecialty) Coding Alert

Published on Fri Mar 28, 2014 PDF

Hint: Even though Medicare won’t pay, don’t write off all other payers. 

Experienced coders know that some payers won’t recognize qualifying circumstances codes (+99100-+99140), but you might have better luck with others. When you’re faced with a claim for a patient of extreme age, keep these three points in mind before adding +99100 (Anesthesia for patient of extreme age, younger than 1 year and older than 70 [List separately in addition to code for primary anesthesia procedure]) to your claim. 

Know When to Consider QC Code Options 

Qualifying circumstances (QC) codes represent specific situations where anesthesia services are particularly difficult. They’re reported in addition to the primary anesthesia code. You’ll find the complete list of QC codes in the Anesthesia Guidelines of CPT®.  

Remember that CPT® classifies these as “add-on” codes, which means you must report them with another code for the main procedure, says Leslie Johnson, CPC, CSFAC, manager of coding, compliance, and education for Somnia, Inc., in New Rochelle, N.Y. 

“These QC codes are essentially ‘added risk’ codes that are inherent to the case at hand (such as emergency and age),” Johnson adds. “These extraordinary risks won’t necessarily be found within the provider’s written documentation as being actually present; they exist by virtue of the condition and circumstance happening all at the same time.”

If you’re able to include +99100 with a claim, it usually will add one base unit to the final unit calculations (which is the suggested relative base value from the American Society of Anesthesiologists). Some private payers may allow more units than ASA recommends.  

Think ‘No’ for Medicare, ‘Possible’ for Other Payers 

Medicare does not recognize or reimburse for qualifying circumstances codes. Many commercial payers, however, recognize the anesthesia guidelines listed in the CPT® manual and accept claims accordingly. 

This includes the guideline giving you the ability to bill separately for as many qualifying circumstances as are applicable, unless a code description is already contained in the description of another code. 

Tip: Some state Medicaid plans might pay for +99100, but you should check with your local state carriers to see if they publish a policy regarding payment. If a payer denies the claim with +99100, be prepared to appeal with documentation.

Follow the Age Guidelines 

Just because the descriptor for +99100 includes age parameters (“younger than 1 year and older than 70”) doesn’t mean you should automatically report the codes for patients in those age ranges. 

Code +99100 shows that the anesthesiologist’s work might be more involved because of a patient’s age. Some anesthesia codes, however, already take this into account. 

Example: Code 00326 (Anesthesia for all procedures on the larynx and trachea in children younger than 1 year of age) includes what’s known as an age qualifier because it specifically tells what age the patient should be when reporting the code. Submitting +99100 is unnecessary when you’re already reporting 00326. 

Other anesthesia codes designated for young children that you shouldn’t report with +99100 include: 

• 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 
• 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. 

The descriptors and base units for these codes already account for the patient’s age and associated risk factors. 

Tip: Coders sometimes debate what “older than 70” means. “Younger than one year” in other code descriptors means up to the date of the patient’s first birthday. The same logic would apply to patients at the other end of the spectrum: “older than 70” would mean you could report +99100 anytime following the patient’s seventieth birthday. 

Final advice: “When people ask about using qualifying circumstances codes, I’ve often told them that their missed opportunity for billing is 100 percent if they aren’t reporting to any carriers,” says Kelly Dennis, MBA, ACS-AN, CANPC, CHCA, CPC, CPC-I,  owner of Perfect Office Solutions in Leesburg, Fla. “They won’t pay for it if you don’t bill it.”