Q: Anesthesia Modifier Coding — Can you go over anesthesia modifiers and when to use them?
A: Yes, I can. Again, I'm going to bring in my doctored up coding manual. I used to be a real neat freak, believe it or not, and I had everything all perfectly lined up. What I found is that if you make your writing too neat it doesn’t jump out off the page at you and that’s what you really want. So, don’t be a neat freak. Don’t worry about writing notes in your book. They are allowed. I just had someone e-mail me yesterday saying, someone came with their chapter and told them that they couldn’t have the E/M tables written in their book like I've been teaching since 1999. So, I sent an e-mail off to our contacts at AAPC and they verified, “No, that’s fine,” so I was able to take that and reply back to the student, “Relax, it’s OK.” They do allow writing in your books. They just don’t allow you to tape, paste, staple, nothing separate, but if you handwrite on a page that already exists in your manuals that’s totally allowable. As you can see, I take great advantage of that allowance.
The question was specifically about anesthesia modifiers. Typically, when we think of a modifier, we think of a two-digit code. In CPT for anesthesia, modifiers can be these physical status modifiers. If you look at them, P1, P2, all the way down to P6, and that’s going to be appended to the CPT code on the claim form to tell the story of how sick a patient was, because if you think about anesthesia, they're trying to quantify the risk. How risky was the procedure, the anesthesia?
Before I really got into coding, unfortunately I had a lot of personal surgeries where I was put under, and even though I was an occupational therapist I didn’t fully appreciate how important anesthesiologists were to keeping you alive. I thought the most important guy was the surgeon. Now, I appreciate that really the anesthesiologist is the one who’s really watching things and they’ll be the one to say, “I think we should stop the procedure,” and they're watching your vitals, they're doing fluids and all that kind of stuff. All of this has to do with the reimbursement formula to figure out how much risk was involved. These are just one set of modifiers here.
When to Use Anesthesia Modifier Coding? – Video
I have the word “required” here because you need to pick one physical status modifier to tell a story of what their status is. So, you’ve got a normal healthy patient. Well, you might think, “Why are they having surgery if they're healthy?” Well, they could have torn meniscus in their knee. Generally, they're healthy. They don’t have other issues like cancer or things like that going on. P2 is a patient with a mild systemic disease. P3 is a severe systemic disease. What’s systemic? It’s something that’s going to affect your whole system, your whole body –hypertension, diabetes – things like that. These numbers I have written in the margin are like a point system, and I’ll explain that in a minute. If you're a normal, healthy patient or you have a mild systemic disease, the risk doesn’t really go up that much. You don’t get any points for it, so to speak. But if they're severe systemic disease they go up one point.
P4: A patient with severe systemic disease that is a constant threat to life. Now, it’s really bumping up two points. P5: moribund. That means death-bound patient who is not expected to survive without the
operation. A very important one there. P6: A declared brain-dead patient whose organs are being
removed for donor purposes. I had a student long ago asked me, “Do they keep them anesthetized because they're not sure if they still feel pain?” I'm like, “No, no it’s not that. It’s about the health of the organs until they get harvested.” That’s why the risk is zero.
Here’s the formula for anesthesia. It’s the only specialty that has its unique way of reporting the units.You're going to have a base anesthesia code and there's a book from the ASA – that’s the Anesthesiology Society – that lets us know the base values of all the codes. This is why it’s not going to be on the CPC exam because you're not going to have this book to bring with you to know the base value. You're going to have this table and you're going to figure out what the base value is for the procedure. You're going to figure out the time units. A unit is normally 15 minutes, so if they were under anesthesia for 60 minutes you're going to report four units of time.
Say, the base value was five and the time value was four, now we’re up to nine points or units, if you will. Then, you're going to finally add the modifiers. We just talked about the physical status modifier. If they were moribund, you're going to get another three points or three units on the claims form. But there’s more that can fall into this modifier’s section.
Let’s look at the second type of modifier. These are actually really add-on codes, but they do modify the claim, so we call them anesthesia modifiers. These actually live in the Medicine section but they're reprinted in the anesthesia guidelines, because that’s what they're used for.
We've got four add-on codes here. These are not required. You only use them if they apply, and you can use more than one; whereas the physical status modifier, you can only use one – either you have a mild systemic disease or you have a moderate one. You can't have both.
Here, 99100 is anesthesia for patient of extreme age which they define for you. You don’t need to say, “Hmm, do I think 50 is of extreme age?” Well, not anymore. So, if they're younger than one or older than 70 – I highlighted younger than one, because we tend to get the old age but we forget that younger than one is extreme age on the other end. If your board exam question or your real-world coding situation says, “69,” that is not older than 70. Don’t over think it. They told you what the definition is.You go by what the manual says. That’s worth one point, by the way, in this formula.
99116 – Anesthesia complicated by utilization of total body hypothermia. What is hypothermia? “Hypo” means below or low and “thermia” temperature. So, lower body temperature. Did they find the patient in a snow bank and their body temperature was low? No. This is when they purposely lower the patient’s body temperature to perform the procedure. There are many procedures that work better when the patient’s body temperature is lowered; but what does it do to the anesthetic risk? It increases it. That’s why this one is worth five points.
99135 — Anesthesia complicated by utilization of controlled hypotension. Now, they're lowering the patient’s blood pressure on purpose to perform the procedure. That’s also worth five points. Then, 99140 is anesthesia complicated by emergency conditions. That’s worth two points. That’s how those modifiers work.
Then, we've got the traditional CPT modifiers -23, -47, -53 and if you're reporting for an ASC, -73 and 74. The -23 is unusual anesthesia. Correct me if I’m wrong, I’m going by memory here. So, unusual anesthesia would be a situation, say, a mentally retarded patient and they need a procedure done that normally you want to put them under anesthesia for, but because they don’t understand and they’re maybe thrashing about and they’re not going to be safe if they proceed that way, they’ll call the anesthesiologist in and put him under anesthesia so the procedure can be done safely. That’s “unusual.”
Now, you would think the diagnosis would help explain the story, but sometimes, oftentimes, the payers want us to use modifiers to tell the story because it’s basically putting the reporting on us and making us explain that there’s a special circumstance, so like, in case of an audit. Say, “Hey! You put the -23 on, where’s your proof?”
Modifier -47 is where the surgeon is actually doing the anesthesia piece. You won’t see this too much nowadays because Medicare doesn’t pay for it, most of the payers don’t pay for it; so surgeons are going to say, “Why am I going to take the risk of doing both the procedure and the anesthesia?” And that would be for procedures maybe like a hand surgery or something that the surgeon, with assistance in the room, would be capable of doing both, but I doubt you’ll ever really run into that in your career.
Modifier -53 is discontinued, so if the procedure isn’t going well, maybe their blood pressure is spiking, going off the chart, the anesthesiologist will say, “We need to discontinue this procedure.”
MAC modifiers – MAC is monitored anesthesia care. What I like to say to myself, “Everything but the knockout” so they’re not being put under, but they’re doing all the monitoring services. So, they’ve got these different modifiers here: QS, G8, G9. I think there’s even more than those.
HCPCS modifiers – that really tell who the players were. These are normally listed before the other modifiers. That’s my note here. You’ve got AA which is basically anesthesiologist is saying “It was performed personally by me.” QS is the MAC modifier. QX is saying it’s a certified registered nurse anesthetist (CRNA) that’s being directed by a physician; whereas QY is they’re being directed by an anesthesiologist. QZ is they are CRNA without direction. AD is medical supervision by a physician who is handling more than 4 concurrent sessions.
Then there might even be more modifiers in HCPCS, but just to give you an idea. There are a whole lot of modifiers going on for anesthesia. So, use the ones that apply to your situation, and hopefully that will help you feel a little bit better about anesthesia modifier coding.