Qualifying circumstances codes identify conditions that significantly affect the nature of the anesthetic service provided. Qualifying circumstances codes should only be billed in addition to the anesthesia service with the highest Base Unit Value. The Modifying Units identified by each code are added to the Base Unit Value for the anesthesia service according to the above Standard Anesthesia Formula.
What is a qualifying circumstances code?
These 5-digit qualifying circumstances codes are recognized as modifiers when they are billed as separate line items in order to report services that were provided under unusually difficult circumstances (i.e. unique operative conditions, extenuating issues with the patient’s condition, etc.).
Are qualifying circumstance codes covered by private payers?
According to our 2018 annual Commercial Conversion Factor survey, approximately 85% of payers covered Qualifying Circumstance codes. As such, it’s important that this be considered in your contracts with private payers.
What are qualifying circumstances for add on codes?
These qualifying circumstances are all add-on codes (meaning that they cannot be billed, alone), and include: Example: A three-month-old female undergoes hernia repair. For proper reimbursement, this add-on code will allow the additional 1 unit of anesthesia to the base units to calculate a higher reimbursement.
What is the qualifying circumstances code for anesthesia?
Qualifying Circumstances Qualifying circumstances are billed using add-on codes, rather than modifiers, that are listed separately in addition to the anesthesia code. Among those codes include the following: 99100 – Anesthesia for patient of extreme age, younger than 1 year and older than 70 (1 unit)
What are qualifying circumstances anesthesia codes?
Qualifying Circumstances99100 – Anesthesia for patient of extreme age, younger than 1 year and older than 70 (1 unit)99116 – Anesthesia complicated by utilization of total body hypothermia (5 units)99135 – Anesthesia complicated by utilization of controlled hypotension (5 units)More items...•
What qualifying circumstances code would be used to identify the administration of anesthesia that is complicated by an emergency condition?
9914099140 – Unit value = 2 Administration of anesthesia complicated by emergency conditions only. An “emergency” is defined as delay in treatment of the patient that would lead to a significantly heightened increase in the threat to life or body part.
Does Medicare pay for qualifying circumstances?
Like Physical Status, the Centers for Medicare & Medicaid Services (CMS) does not recognize Qualifying Circumstances for additional payment, but many private payers do.
What ages qualify for add on code 99100?
This is an add–on code, used along with a primary anesthesia procedure code, and is applied only in cases when the patient's age is less than 1 year or more than 70 years.
What are the three classifications of anesthesia?
There are three types of anesthesia: general, regional, and local. Sometimes, a patient gets more than one type of anesthesia. The type(s) of anesthesia used depends on the surgery or procedure being done and the age and medical conditions of the patient.
What are P codes and anesthesia modifiers?
Anesthesia Payment Basics Series: #4 Physical StatusModifierCPT/HCPCS DescriptorP2A patient with mild systemic diseaseP3A patient with severe systemic diseaseP4A patient with severe systemic disease that is a constant threat to lifeP5A moribund patient who is not expected to survive without the operation2 more rows
What does modifier P1 mean?
Modifier P1 A normal healthy patient. Modifier P2 A patient with mild systemic disease. Modifier P3 A patient with severe systemic disease. Modifier P4 A patient with severe systemic disease that is a constant threat to life.
What is a category code?
Category codes are user defined codes to which you can assign a title and a value. The title appears on the appropriate screen next to the field in which you type the code.
How are Mac services coded?
Monitored anesthesia care (MAC), like Propofol® for example, Codes 00100-01999, is a specific anesthesia service for a diagnostic or therapeutic procedure.
How many possible add on qualifying circumstances are there in the anesthesia section?
How many possible add-on qualifying circumstances are there in the Anesthesia Section? (There are four add-on codes to indicate important circumstances and these are called qualifying circumstances.)
Is 99100 covered by Medicare?
First of all, 99100 is an anesthesia qualifying circumstance that can only be billed if the patient is over 70 and does NOT have Medicare as primary. Otherwise you cannot bill 99100 to Medicare products as they won't pay for this.
What does CPT code 99100 mean?
Code Definition. 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)
Anesthesia Modifiers
Modifiers are two-digit codes added to CPT and HCPCS codes that provide additional or more detailed information. They are divided into two levels and two categories.
Physical Status Codes
The following modifiers are used to indicate physical status during the anesthesia procedure.
Qualifying Circumstances
Qualifying circumstances are billed using add-on codes, rather than modifiers, that are listed separately in addition to the anesthesia code. Among those codes include the following:
Learn More
For more information about Anesthesia Modifiers, Physical Status, and Qualifying Circumstances, check out these resources:
What is the code for lowering blood pressure?
Code +99116 and +99135 cover the intentional and possibly pharmacologic lowering of a patient’s body temperature or blood pressure. For that reason, these codes are not reported with cardiac procedures performed with cardiopulmonary bypass when hypothermia or hypotension may be the result of being on bypass.
What is CPT code 27506?
A patient covered by a private plan that includes coverage for Qualifying Circumstances and Physical Status undergoes the procedure as described by CPT code 27506 - Open treatment of femoral shaft fracture, with or without external fixation, with insertion of intramedullary implant, with or without cerclage and/or locking screws - under emergency conditions to repair an open (compound) fracture. Per the ASA CROSSWALK®, this anesthesia care may be described with anesthesia CPT code 01230 - Anesthesia for open procedures involving upper two-thirds of femur; not otherwise specified – which has 6 base units. We will assume anesthesia time of 139 minutes and that the payer uses a 15-minute time unit computing time out to one decimal point. The conversion factor is $72.00 per unit.#N#If the patient’s Physical Status is ASA II and s/he is 72 years old, reporting may be as follows:
What is a modifier 59?
The CMS NCCI Policy manual states that "many standard preparation, monitoring, and procedural services are considered integral to the anesthesia service. Although some of the services would never be appropriately reported on the same date of service as anesthesia management, many of these services could be provided at a separate patient encounter unrelated to the anesthesia management on the same date of service." Anesthesia Professionals may identify these separate encounters by reporting a modifier 59, XE or XU. For CPT and HCPCS codes included on the Procedural or Pain Management Codes Bundled into Anesthesia list that will be considered distinct procedural services when modifier 59, XE or XU is appended, refer to the following list:
What is CPT code 01996?
Daily hospital management of epidural or subarachnoid drug administration (CPT code 01996) in a CMS place of service 19 (off campus outpatient hospital), 21 (inpatient hospital), 22 (on campus outpatient hospital) or 25 (birthing center) is a separately reimbursable service once per date of service excluding the day of insertion. CPT code 01996 is considered included in the pain management procedure if submitted on the same date of service by the Same Individual Physician or Other Qualified Health Care Professional.
What is the CPT code for anesthesia?
Anesthesia services must be submitted with a CPT anesthesia code in the range 00100-01999 , excluding 01953 and 01996, and are reimbursed as time-based using the Standard Anesthesia Formula. Refer to the attached Anesthesia Codes list for all applicable codes.
What is a 1500 claim form?
This reimbursement policy applies to services reported using the 1500 Health Insurance Claim Form (a/k/a CMS-1500) or its electronic equivalent or its successor form. This policy applies to all products, all network and non-network physicians and other qualified health care professionals, including, but not limited to, non-network authorized and percent of charge contract physicians and other qualified health care professionals.
Can you use the same anesthesia code for the same patient?
When duplicate (same) anesthesia codes are reported by the same or different physician or other qualified health care professional for the same patient on the same date of service, UnitedHealthcare will only reimburse the first submission of that code. However, anesthesia administration services can be rendered simultaneously by an MD and a CRNA during the same operative session, each receiving 50% of the Allowed Amount (as indicated in the Modifier Table above) by reporting modifiers QK or QY and QX.
Monday, May 16, 2016
Qualifying circumstances are those factors such as extreme age, extraordinary condition of the patient, and unusual risk factors which may affect the anesthesia services. These procedures are considered add-on codes and would not be reported alone, but as additional procedures qualifying an anesthesia procedure or service.
What is Qualifying Circumstances ?
Qualifying circumstances are those factors such as extreme age, extraordinary condition of the patient, and unusual risk factors which may affect the anesthesia services. These procedures are considered add-on codes and would not be reported alone, but as additional procedures qualifying an anesthesia procedure or service.

Anesthesia Modifiers
Physical Status Codes
- The following modifiers are used to indicate physical status during the anesthesia procedure. 1. P1 – A normal healthy patient 2. P2 – A patient with mild systemic disease 3. P3 – A patient with severe systemic disease 4. P4 – A patient with severe systemic disease that is a constant threat to life 5. P5 – A moribund patient who is not expected to survive without the operation 6. P6 – A …
Qualifying Circumstances
- Qualifying circumstances are billed using add-on codes, rather than modifiers, that are listed separately in addition to the anesthesia code. Among those codes include the following: 1. 99100 – Anesthesia for patient of extreme age, younger than 1 year and older than 70 (1 unit) 2. 99116 – Anesthesia complicated by utilization of total body hypothe...
Learn More
- For more information about Anesthesia Modifiers, Physical Status, and Qualifying Circumstances, check out these resources: 1. ASA’s Timely Topics in Payment and Practice Management 2. WPS GHA’s Anesthesia Physical Status Modifier Fact Sheet 3. CIPROMS blog post “Not Sure if You’re Billing Anesthesia Modifiers Correctly? Here’s a Refresher” — All rights reserved. For use or repri…