Anesthesia services are provided under difficult circumstances which may affect the condition of the patient, or present unusual operative conditions and / or risk factors.
Codes and Definitions
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)
99116 Anesthesia complicated by utilization of total body hypothermia (List separately in addition to code for primary anesthesia procedure)
99135 Anesthesia complicated by utilization of controlled hypotension (List separately in addition to code for primary anesthesia procedure)
99140 Anesthesia complicated by emergency conditions (specify) (List separately in addition to code for primary anesthesia procedure)
This code is eligible for separate reimbursement at the allowed amount. Separately in addition to code for primary anesthesia proedure. Thi code are assigned a status indicator of “B” (bundled code) on the CMS Physician Fee schedule, and are not eligible for separate reimbursement uder Medicare guidelines. As per CMS, the value for the qualifying circumstances has already been included in the RVUs for the primary anesthesia procedure codes. Payment for these services is always included in payment for other services not sprcified. There are no RVUs or payment amoount for these codes and separate payment is not made.
Reimbursement Guidelines
Commercial lines of business
Effective for claims processed on or after 2/25/2016, Moda Health does not separately reimburse for CPT codes 99100 – 99140. This is based on their status indicator of “B” (bundled code) on the CMS Physician Fee Schedule.
CPT codes 99100 – 99140 will deny to provider liability with denial codes:
EX: 2M0 Service/supply is considered bundled or incidental. Not eligible for separate payment. Always bundled into a related service.
CARC: 97 The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated.
RARC: M15 Separately billed services/tests have been bundled as they are considered components of the same procedure. Separate payment is not allowed.
99100+ (Anesthesia for patient of extreme age, under 1 year and over 70 {list separately in addition to code for primary procedure}) bundles with 00326 (Anesthesia for all procedures on the larynx and tracheas in children less that 1 year of age), 00834 (Anesthesia for hernia repair in the lower abdomen (not otherwise specified, under 1 year of age) and 00836 (Anesthesia for hernia repair in the lower abdomen not otherwise specified, infants less that 37 weeks gestational age at birth and less than 50 week gestation age at time of surgery).
Claims Example
A Blue Cross member has a cholecystectomy that requires 50 minutes of anesthesia. Due to the fact that the member is over age 70, Procedure 99100 is also billed. The claim submitted by the anesthesiologist to Blue Cross should include the appropriate information explained above. The claim for covered services is processed as follows to determine the Allowable Charge:
The Base Units value should never be included in the “units” field of your claim.
Procedure 99100 (Payment is based on the allowable charge). The totals noted in each of these examples do not include the payment for the qualifying circumstance Procedure 99100 that was applicable in the example.
Additional reimbursement for Procedure 99100 will be based on the provider’s allowable charge.
If any modifiers were applicable for physical status, those units would be added to the above calculations as noted in the formulas. The allowable charges represent the total amount collectable from Blue Cross and the member (if deductible, copayment and/or coinsurance apply). The difference between the provider’s charge and the allowable charge is not collectable from the member.
Coding Guidelines
CPT Assistant:
“Question: What are “qualifying circumstances for anesthesia,” and when are they reported?
Answer: Codes 99100-99140 are add-on codes that include a list of important qualifying circumstances that significantly affect the character of the anesthesia service provided. These circumstances would be reported as additional procedure numbers qualifying an anesthesia procedure or service. More than one code in the section may be selected, if applicable. Codes 99100-99140 are listed in the Anesthesia guidelines in the CPT codebook.” (AMA2)
Medicare Physician Fee Schedule:
Qualifying circumstances CPT codes 99100 – 99140 are assigned a status indicator of “B” (bundled code) on the CMS Physician Fee Schedule, and are not eligible for separate reimbursement under Medicare guidelines. Per CMS, the value for these qualifying circumstances has already been included in the RVUs for the primary anesthesia procedure codes.
Documentation Requirements
All billing should be supported by the anesthesia record. Records are required with claims submissions in the following cases:
• Submission of any miscellaneous procedure codes; for example, Procedure 01999. Because the code does not provide sufficient information, the record is necessary to identify the actual procedure performed.
• Anesthesia administered for dental procedures. Because dental coverage guidelines may be limited, the anesthesia record will help us to make coverage determination on each case.
• If two different anesthesia services are billed on the same claim with the same performing provider identifier (NPI), the anesthesia record is needed to document that two different operative sessions occurred on the same day.
• If a procedure is billed that is not site-specific, we may request the anesthesia record to determine the site to ensure coverage should be allowed.
Blood Gas Monitoring
Blood gas monitoring performed as part of an anesthesiologist’s service is considered to be an integral part of the anesthesia service and is not reimbursed separately.
Bundled Services
CPT Code Description
99100 Special anesthesia service
99116 Anesthesia with hypothermia
99135 Special anesthesia procedure
99140 Emergency anesthesia
Separate payment will not be allowed for these services; payment will be bundled into the anesthesia allowance.
Qualifying Circumstances
Sometimes anesthesia services are provided under difficult circumstances which may affect the condition of the patient, or present unusual operative conditions and/or risk factors. The following codes are used to identify these circumstances and are reported in addition to the anesthesia procedure or service provided.
99100 – Anesthesia for patient of extreme age, younger than 1 year and older than 70.
99116 – Anesthesia complicated by utilization of total body hypothermia
99135 – Anesthesia complicated by utilization of controlled hypotension
99140 – Anesthesia complicated by emergency conditions (specify)
Qualifying circumstances CPT codes 99100-99140 represent the provision of anesthesia services under particularly difficult circumstances that necessitate the skills of a physician beyond those usually required.
Anesthesia Qualifying Circumstances (99100-99140) do not require prior authorization.
You must report the appropriate qualifying circumstances code in addition to the anesthesia CPT code on the same claim. Do not report units. (This applies to both paper and electronically billed claims.) You must also report the applicable anesthesia modifier with the qualifying circumstance code.
Exception: You can report physical status with the applicable modifier. Report this modifier only in conjunction with the appropriate anesthesia procedure code (00100-01999):
Modifier Description Modifying units
P1 A normal healthy patient (Physical status 1) 0
P2 A patient with mild systemic disease (Physical status 2) 0
P3 A patient with severe systemic disease (Physical status 3) 1
P4 A patient with severe systemic disease that is a constant 2 threat to life (Physical status 4)
P5 A moribund patient who is not expected to survive 3 without the operation (Physical status 5)
P6 A declared brain-dead patient whose organs are being removed for donor purposes (Physical status 6) 0
HMO, PPO, Individual Marketplace, Elite, Advantage
Paramount recognizes anesthesia qualifying circumstances (99100-99140) as eligible for separate reimbursement.
Paramount does not recognize Physical Status Modifiers, P1-P6, for additional reimbursement for anesthesia on patients with critical physical status. As an exception to the Status B indicators set by Medicare, anesthesia qualifying circumstances (99100-99140) should be used for these situations.
The appearance of a code in this section does not necessarily indicate coverage. Codes that are covered may have selection criteria that must be met. Payment for supplies may be included in payment for other services rendered.
99100 Anesthesia for patient of extreme age, younger than 1 year and older than 70
99116 Anesthesia complicated by utilization of the total body hypothermia
99135 Anesthesia complicated by utilization of controlled hypotension
99140 Anesthesia complicated by emergency conditions
These codes are eligible for separate reimbursement at the allowed amount. The Health Plan uses claims processing logic based on ClaimsXten ®’? rationale to determine when there may be a mutually exclusive relationship with the reported base anesthesia code.*
* Note: Based on the ASA RVGcomment which states that “qualifying circumstances codes (+99100 through +99140) should not be reported with 01996,”1 the Health Plan will deny the qualifying circumstances code(s) 99100, 99116, 99135, or 99140 as mutually exclusive if billed with 01996 (daily hospital management of epidural or subarachnoid continuous drug administration).
CPT 99140 is eligible for separate reimbursement for emergency services. However, if 99140 is reported for an unscheduled routine obstetric delivery with the one of the diagnosis codes listed below, 99140 will not be eligible for separate reimbursement.
Empire BlueCross and BlueShield Professional Reimbursement Policy
Sometimes anesthesia services are provided under difficult circumstances which may affect the condition of the patient, or present unusual operative conditions and/or risk factors. The following codes are used to identify these circumstances and are reported in addition to the anesthesia procedure or service provided.
99100 Anesthesia for patient of extreme age, younger than 1 year and older than 70
99116 Anesthesia complicated by utilization of the total body hypothermia
99135 Anesthesia complicated by utilization of controlled hypotension
99140 Anesthesia complicated by emergency conditions
These codes are eligible for separate reimbursement at the allowed amount. The Health Plan uses claims processing logic based on ClaimsXten ®’? rationale to determine when there may be a mutually exclusive relationship with the reported base anesthesia code.
** Note: Based on the ASA RVGcomment which states that “qualifying circumstances codes (+99100 through +99140) should not be reported with 01996,”1 the Health Plan will deny the qualifying circumstances code(s) 99100, 99116, 99135, or 99140 as mutually exclusive if billed with 01996 (daily hospital management of epidural or subarachnoid continuous drug administration).
CPT 99140 is eligible for separate reimbursement for emergency services. However, if 99140 is reported for an unscheduled routine obstetric delivery with the one of the diagnosis codes listed below, 99140 will not be eligible for separate reimbursement.
99100 “(List separately in addition to code for primary anesthesia procedure)”
99100 Special anesthesia service
* Anesthesia qualifiers, which include qualifying circumstance CPT codes (99100, 99116, 99135, 99140) and physical status modifiers (P1-A – P6-A)
Positioning of the Patient
Positioning the patient (e.g., lithotomy, lateral, prone, sitting, field avoidance) before, during, or following a therapeutic procedure, is considered incidental to other services provided and is not reimbursed separately.
Qualifying Circumstances for Anesthesia
Reimbursement for Qualifying Circumstances for Anesthesia (99100-99140) is included in the basic allowance for other anesthesia procedures (00100-01999), when performed on the same day by the same provider.
Local anesthesia
Local anesthesia is considered to be an integral part of the surgical procedure and no additional reimbursement is provided.
Multiple Surgical Procedures
When multiple surgical procedures are performed, the base value of anesthesia is the base value for the procedure with the highest relative unit value. No reimbursement is provided for the base unit values of additional procedures. Time units cover the additional time required for these procedures.
Pre-anesthesia Evaluation
A pre-anesthesia evaluation by the anesthesiologist when surgery is canceled may be covered at the level of care rendered (e.g., brief or limited visit) as a hospital or office visit.
A pre-anesthesia evaluation by the anesthesiologist when the procedure is delayed is not eligible for coverage as a separate procedure. It is an integral part of the subsequent anesthesia services. Anesthesia Administered by the Operating Surgeon Reimbursement for general anesthesia or intravenous analgesia administered by the operating surgeon, assistant surgeon, or obstetrician is included in the basic allowance for the surgical procedure performed.
Transesophageal Echocardiography
In accordance with the correct coding initiative, effective October 23, 2008, Transesophageal Echocardiography (TEE) Placement and Interpretation is no longer considered for separate reimbursement in addition to payment for the primary anesthesia procedure. However, when this service is performed for diagnostic purposes and documentation is provided to include a formal report, this service may be considered for separate reimbursement in accordance with CMS guidelines.
Ventilation Management
Ventilation Assist and Management is a covered service. This service is not necessarily confined to the critical care area. It can be rendered in a hospital setting, or in rare cases rendered in extended care facilities or the home setting. Reimbursement for initial ventilation and management is limited to one within a 30-day period. Effective January, 2007, Ventilation Assist and Management is incidental to the anesthesia service when it is performed on the same day as the anesthesia.
Epidurals
Epidural analgesia involves the administration of a narcotic drug through an epidural catheter. When performed as the primary type of anesthesia, the time required is included in the total anesthesia minutes reported.
A continuous epidural reported using procedure code 62319 is reimbursed only one time, as a flat rate code.
CPT Coding: 00100 – 01999
Anesthesia (site specific)
99100* Anesthesia for patient of extreme age, under one year and over seventy (List separately in addition to code for primary anesthesia procedure)
99116* Anesthesia complicated by utilization of total body hypothermia (List separately in addition to code for primary anesthesia procedure)
99135* Anesthesia complicated by utilization of controlled hypotension (List separately in addition to code for primary anesthesia procedure)
99140* Anesthesia complicated by emergency conditions (specify) (List separately in addition to code for primary anesthesia procedure)
* NOTE: Qualifying Circumstances for Anesthesia is included in the basic allowance for anesthesia procedures.
47 Anesthesia by surgeon
P1 A normal healthy patient
P2 A patient with mild systemic disease
P3 A patient with severe systemic disease
P4 A patient with several systemic disease that is a constant threat to life
P5 A moribund patient who is not expected to survive without the operation
P6 A declared brain-dead patient whose organs are being removed for donor purposes
NOTE: Additional reimbursement is not provided for the physical status (P) modifiers
HCPCS Coding/Modifiers:
AA Anesthesia services performed personally by anesthesiologist
AD MD supervision, more than 4 anesthesia services
G8 Monitored anesthesia care (MAC) for deep complex, complicated, or markedly invasive surgical procedure
G9 Monitored anesthesia care for patient who has history of severe cardiopulmonary condition
QK Medical direction of two, three, or four concurrent anesthesia procedures involving qualified individuals
QS Monitored anesthesia care service
QX CRNA service; with medical direction by a physician
QY Medical direction of one certified registered nurse anesthetist (CRNA) by an anesthesiologist
QZ CRNA service; without medical direction by a physician
