Anesthesia modifiers: They’re an integral part of anesthesia coding and billing, but are you using them properly? It’s no easy task given the sheer number and different types of modifiers: from Current Procedural Terminology (CPT®), Relative Value Guide (RVG®) and Healthcare Common Procedure Coding System (HCPCS) modifiers to pricing and information modifiers. And then you must know which modifiers to report, in which order.
The incorrect use of modifiers ranks among the top billing errors for federal, state, and private payers, according to coding instructor Kelly Dennis. But you can avoid falling into common traps, assures Dennis in her “Anesthesia Modifiers” presentation, part of ProfEdOnDemand’s 2019 Coding Updates Virtual Boot Camp, in which she demystifies modifier ranking order and explains how modifiers affect payment.
Differentiate: Performed, Directed, or Supervised
A great way to start is by polishing up your Anesthesia CPT® code practices. Specifically, let’s take a look at pricing and informational modifiers. Reimbursement hinges on your ability to pick the correct modifier(s) and place them in the right order, but don’t stress out. Here’s a quick breakdown:
Pricing modifiers
These modifiers must always go in the first modifier slot. They indicate who performed, supervised, or directed a particular service and are reimbursed at different percentages. Pricing modifiers include:
- AA: Anesthesiology services were performed only by the anesthesiologist
- AD: Services were supervised by a physician, 4+ concurrent procedures
- QK: Medical direction of 2-4 concurrent procedures involving qualified individuals (e.g., Certified Registered Nurse Anesthetist (CRNA), Anesthesiologist Assistant (AA), intern or resident)
- QX: Services performed by a qualifying non-physician anesthetist under the medical direction of a physician
- QY: Services performed by a qualifying non-physician anesthetist and supervised by an anesthesiologist
- QZ: Services provided by a CRNA, with no medical direction from a physician
Pay Attention: As you’ve probably noticed, many of the definitions above differ only slightly. For instance, the difference between QX and QY is whether there was direction or supervision. Medical direction is more involved than supervision and includes 7 steps. These steps include performing a pre-anesthesia evaluation, creating an anesthesia plan, and providing care post-anesthesia. With a few exceptions, medical supervision is the default if not all 7 steps for medical direction were followed.
Informational Modifiers
Informational modifiers should always be placed after pricing modifiers. Unlike pricing modifiers, informational modifiers do not affect reimbursement. Nevertheless, there are important to painting a full picture of what happened. There are quite a few of these, but for now let’s look at just monitored anesthesia care (MAC services) modifiers and -23.
MAC services refer to planned procedures where a patient is given local anesthesia (affecting only a restricted area of the body), analgesia, and sedation. The three modifiers are GS, G8, and G9:
- QS: MAC services
- G8: MAC services performed for a highly complex or invasive surgical procedure
- G9: MAC services for a patient with a history of a serious cardiopulmonary condition
Modifier -23 (unusual anesthesia) refers to procedures that typically would require only local anesthesia or no anesthesia, but, due to unusual circumstances, general anesthesia was given to the patient. To use modifier -23, the unusual circumstances requiring anesthesia must be described in the documentation or payers won’t reimburse for this modifier. A typical example of a situation requiring -23 would be of a patient becoming unable to control his or her own airway, and general anesthesia was required.
Think Like a Payer
Remember: When billing, follow the idea of “if it wasn’t documented, it never happened.” Payers may request to see patient records, says Dennis, and if they don’t see evidence for the Anesthesia modifiers you used, claim denials may swiftly follow. And, as always, brush up on individual payer rules. Payer A may have different requirements or reimbursement rates from Payer B for a particular modifier.
All the rules, definitions, and nitpicky details may have derailed your focus on a claim or two in the past, but bone up on your anesthesia coding knowledge now to banish confusion! Your practice will be grateful.
