Reporting any qualifying circumstances (QC) codes for anesthesia can be tricky, but knowing when to classify a situation as a true emergency can be a real challenge unless you’re well-versed in the emergency conditions guidelines. Check coding definitions and your provider’s documentation to know whether you can legitimately add two extra units for +99140 (Anesthesia complicated by emergency conditions [specify] [List separately in addition to code for primary anesthesia procedure]) to your claim.
CPT includes a note with +99140 stating that “an emergency is defined as existing when delay in treatment of the patient would lead to a significant increase in the threat to life or body parts.” Your key to knowing a case meets emergency conditions lies in your anesthesiologist’s notes.
“Quite a number of cases come in where the anesthesiologist marks ‘emergency’ but many times the ‘emergency’ isn’t all that clear,” says Leslie Johnson, CCS-P, CPC, director of coding and education for Medi-Corp., Inc., of New Jersey. Documentation supporting an emergency will depend on each case, so read the chart thoroughly when your provider indicates an emergency.
Solution: Talk with your anesthesia providers to clarify what constitutes an emergency and when you can include +99140. If there’s a real reason to report an emergency (such as a ruptured appendix, 540.0), your physician should clearly document the reason. Another diagnosis code to indicate a problem (such as unstable angina, 411.1) could help show the payer you’re reporting an unusual situation. The second diagnosis can also help in an appeal if a payer that ordinarily recognizes +99140 denies the claim.
“An OB patient who comes in for a cesarean section isn’t automatically an emergency,” explains Scott Groudine, M.D., professor of anesthesiology at Albany Medical Center in New York. “However, a diagnosis of fetal distress and prolapsed cord virtually always implies an emergency that can’t wait.” Under these circumstances, you could be justified in reporting +99140.
Remember ‘Unexpected’ Doesn’t Equal ‘Emergency’
Some physicians tend to add “emergency” to unexpected events, such as after hours or weekend cases they get called to attend. Timing alone isn’t enough to merit +99140, according to the Relative Value Guide (RVG).
Remember, when considering whether to report +99140, always ask yourself whether delaying treatment would have led to a significant increase in risk to the patient’s life or limb. If not, you shouldn’t include +99140.
Take for example, an 80-year-old man is admitted to the hospital with a hip fracture. The cardiologist won’t clear the patient for surgery until he has an echocardiogram the next day. Delaying surgery because of the echocardiogram doesn’t constitute an emergency. “Any case where you can wait eight hours for the patient’s stomach to empty or one to two days for cardiac optimization is not a true emergency,” Groudine says.
Follow the Payer’s Guidelines
Even if a case qualifies as an emergency, check the payer in question’s guidelines before automatically including +99140. Not every payer (including Medicare) recognizes qualifying circumstances codes or pays additional units for their use. But for payers that reimburse, you can add two base units to the claim.
Tip: Several state Medicaid plans pay for emergency circumstances but others won’t. You can’t negotiate payment with Medicaid — either they cover qualifying circumstances codes or they don’t — but do discuss qualifying circumstances when negotiating contracts with non-government payers. Include a contractual clause stating whether the payer reimburses based on the ASA’s RVG. If so, you can include a copy of the RVG page to remind the payer of your expected payment. You can also include the RVG page or CPT guidelines stating that an emergency is separately billable if you receive a denial and need to go through the appeal process. Join Supercoder.com to stay updated with the CPT guidelines.