what is qualifying circumstances

Qualifying circumstances.
Anesthesia services, which are provided under particularly difficult circumstances, may warrant additional reimbursement for unit values based on unusual events. This subsection includes a list of important qualifying circumstances that impact the anesthesia service provided. These procedures are not reported alone but are reported as additional procedure numbers qualifying an anesthesia procedure for additional reimbursement. The listed unit value must be added to the basic unit values to obtain the reimbursement (see Section IX. A. 2.a.(5)). List each of the following codes separately in addition to the procedure code for the primary anesthesia procedure.

Qualifying Circumstances                                            Unit Values
99100 Anesthesia for patient of extreme age, under one year and over seventy 1 99116 Anesthesia complicated by utilization of total body hypothermia 5 99135 Anesthesia complicated by utilization of controlled hypotension 5 99140 Anesthesia complicated by emergency conditions (specify) 2
Qualifying Factors

Physical Status

If physical status modifiers are applicable, the modifier should be indicated on the CMS-1500 claim form (Block 24d or the equivalent field on electronic claims) by the letter P followed by a single digit from one (1) to six (6). Additional units may be allowed when the claim indicates any of the following:

P1 A normal patient 0 units

P2 A patient with mild systemic disease 0 units

P3 A patient with severe systemic disease 1 unit

P4 A patient with severe systemic disease that is a constant threat to life 2 units

P5 A moribund patient who is not expected to survive without the operation 3 units

P6 A declared brain dead patient whose organs are being removed for donor purposes  0 units

What is Qualifying Circumstances 

When any of the CPT codes defined in this section are provided in addition to anesthesia procedures, the allowable charge is the basis for reimbursement. Do not bill these procedures with anesthesia modifiers, physical status modifiers or anesthesia minutes; otherwise, delay or rejection of payment may occur. 

• Qualifying circumstances are those factors that significantly affect anesthesia services. Examples are the extraordinary condition of the patient, notable operative conditions and unusual risk factors. These procedures would not be reported alone, but as additional procedures qualifying an anesthesia procedure or service. Each qualifying circumstance is listed here: 99100; 99116; 99135; 99140.

• Specialized forms of monitoring also fall into the category of Qualifying Circumstances. Those that qualify are listed below. Although there are other forms of monitoring that are not listed here, these are the only ones for which an additional amount may be allowed. Any other charges should be combined with the total charge without an additional allowable charge. When billed in conjunction with an anesthesia procedure, the following CPT codes or combination of CPT codes are reimbursed  over and above the anesthesia procedure, based on the provider’s allowable charge and medical necessity.

• Arterial line (36620 or 36625)

• Central venous line (36555; 36556; 36568; 36569; 36580; or 36584)

• Swan Ganz line (93503)

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