Emergency Anesthesia Modifier – ZB, cpt Q5102, Q9981

Emergency Anesthesia Modifier:  Healthy Patient

Modifier -ZB may be used to bill for anesthesia services during an emergency procedure on an otherwise healthy or medically stable and uncompromised patient.  Examples of the appropriate use of modifier -ZB are an otherwise healthy adult patient who presents with acute appendicitis, a pediatric patient who presents with a torsion of the testis or a patient who requires a non-elective cesarean section.  Modifier -ZB will add one unit to the basic anesthesia unit value of any procedure that is performed in an emergency situation.  Modifiers -P3 and -P4 with ICD-9 diagnosis code 995.89 (other Hypothermia due to anesthesia), -P5 with -ET (emergency services) or -ZD are not reimbursable under these circumstances.

Anesthesia Risk/ Emergency Modifiers

An additional charge may be warranted in cases where patients present for anesthesia with certain complications and/or emergency conditions.  Identify such cases by adding the appropriate modifier to the five-digit CPT-4 anesthesia code and include documentation of the condition and the patient’s American Society of Anesthesiology (ASA) Physical Status Class in the Remarks area/Reserved For Local Use field (Box 19) of the claim or attached to the paper claim.

Quarterly Healthcare Common Procedure Coding System (HCPCS) Drug/Biological Code Changes 

Provider Action Needed

Change Request (CR) 9636 informs Medicare providers and suppliers that effective for claims with dates of service on or after July 1, 2016, new Healthcare Common Procedure Coding System (HCPCS) codes Q9981 (rolapitant, oral, 1mg); Q9982 (flutemetamol f18 diagnostic); and Q9983 (florbetaben f18 diagnostic) will be payable for Medicare. In addition, the HCPCS code set will contain code Q5102 (Inj., infliximab biosimilar), which is effective for dates of service on or after April 5, 2016. Claims for Q5102 must also have the modifier ZB (Pfizer/hospira). Make sure that your billing staffs are aware of these changes.

Q5102: Effective April 5, 2016, Q5102 (Inj., infliximab biosimilar) is payable in the ASC setting, where there has not previously been a specific code available. Also effective April 5, 2016, Q5102 must be submitted with a modifier to identify the manufacturer of the biosimilar product. Currently, the ZB modifier is the only manufacturer/modifier that may be submitted with this HCPCS. Claims submitted without the modifier cannot be processed.

The HCPCS code set is updated on a quarterly basis. The July 2016 HCPCS file includes four new HCPCS codes, Q9981 rolapitant, oral, 1mg, Q9982 flutemetamol f18 diagnostic, Q9983 florbetaben f18 diagnostic and Q5102 Inj., infliximab biosimilar. Also, the July 2016 HCPCS file includes a new HCPCS modifier, ZB Pfizer/hospira.

Add modifier ZB (Pfizer/Hospira) to the list of valid modifiers.

Apply the edit if new biosimilar HCPCS code Q5102 is reported without the associated new modifier ZB.

What this means to you: For claims with dates of service on or after July 1, 2016, there will be health care procedure codes that will be covered. Refer to the CPT codebook for complete descriptions

The following procedure codes will be considered for coverage:

C9476 C9477 C9478
C9480 Q5102 Q9981

Effective with dates of service on or after July 1, 2016, modifier ZB (Pfizer/Hospira), an informational modifier denoting the manufacturer of a biosimilar product, must be submitted with HCPCS code Q5102. If not, Q5102 will be denied.

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