Circumstantial Evidence: Supporting Claims for Qualifying Circumstances

The CSI lab doesn’t always come up with the goods.  Sometimes, the smoking gun just isn’t there.  But you don’t always need DNA samples or fingerprint matches to raise questions about a particular suspect.  Sometimes, a perp can go down based on nothing more than “circumstantial evidence,” like being in the wrong place at the wrong time—in connection with multiple crime scenes.  Yeah, that’s a little sus.

If you were to turn to the introductory section of the Relative Value Guide (RVG)—a publication of the American Society of Anesthesiologists (ASA)—you would find a list of services under the title “Qualifying Circumstances.”  The list reveals four add-on codes, along with their descriptors.  An add-on code cannot be listed separately on a claim form; it can only be listed when the primary code appears on the claim.  In the case of qualifying circumstances, that primary code must be an anesthesia code.

But a claim for extra payment will mean extra scrutiny by the payer.  Their in-house or contracted auditors will want to see evidence of the specific circumstances being claimed (literally, “circumstantial evidence”).  When it comes to surviving a government or commercial payer audit (think of it as sort of a forensic investigation), clinicians are required to provide proof that they actually performed the services for which they billed.  That proof comes in the form of data documented on the medical record.

So, what are these qualifying circumstances?  Who pays for them?  And what must be documented to survive a post-payment audit?  Let’s take a closer look.

Extreme Age

The first of these qualifying circumstances is reflected by add-on code 99100, with an initial descriptor of “Anesthesia for patient of extreme age.”  Now, no one would be thrilled to have that description applied to themselves.  That characterization sounds a bit, well, extreme!  This becomes particularly evident when you realize that, by “extreme age,” they simply mean a patient “over 70.”  Haven’t they heard that 70 is the new 50?!

But the extremity factor goes both ways.  The code is not only for those over 70 (the upper end of the age spectrum); it can also be applied when the patient is under one year old (the lower end).  While the “younger than one year” requirement is straightforward enough, there may be a question about what is meant by the “older than 70” portion of the code descriptor.  Does that mean they must be 71 or older, or does that mean they must be at least 70?  Fortunately, the RVG contains a clarifying note that indicates the code would be appropriate to list when the patient is at least one day beyond 70 years old.  So, you wouldn’t be able to use this code if the service took place on the patient’s 70^th birthday, but you could if the service occurred the day after.

Medicare does not pay for this code, but for those payers that do reimburse 99100, the ASA’s RVG recommends one base unit added to the total payment.  The RVG notes that you cannot apply this code in conjunction with codes 00326, 00561, 00834 and 00836.

This is the only qualifying circumstance where the anesthesia provider typically will not need to directly add notations in the anesthesia record to support the claim, as the patient’s date of birth is already part of the overall medical record and demographic data.

Hypothermia and Hypotension

Add-on code 99116 is listed on the claim when anesthesia is complicated by the utilization of total body hypothermia, while add-on code 99135 describes anesthesia complicated by controlled hypotension.  Each code pays five additional base units.  Again, Medicare does not provide reimbursement for these codes.

According to the ASA, these codes should only be used to reflect the intentional and possibly pharmacologic lowering of a patient’s body temperature or blood pressure.  For this reason, 99116 and 99135 cannot be reported with cardiac procedures performed with cardiopulmonary bypass when hypothermia or hypotension may be the result of being on bypass.  Accordingly, providers should not use these add-on codes in tandem with 00562, 00563 and 00567.

If you utilized “total body hypothermia” or “controlled hypotension,” your documentation should reflect such utilization.  It may be helpful to also list the medical rationale for the service, along with supporting metrics or monitoring data.  Finally, according to AAPC coding articles, the anesthesia provider should document in the anesthesia record that these services were performed based on the surgeon’s request, where applicable.

Emergency

The final qualifying circumstances category involves “anesthesia complicated by emergency conditions,” as reflected by add-on code 99140.  As with all qualifying circumstances, Medicare will not pay for this code; but, for those that do, the RVG lists the service at two base units.

Providers should be reminded that this code can only be used in true emergency situations.  The RVG describes these situations as follows: “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 part.”

This raises an important point: not every unscheduled or after-hours surgery or C-section is an emergency.  So, you’ll want to be judicious in the use of such claims.

If the service, in your clinical judgment, meets the RVG threshold as cited above, then your documentation should include (a) an indication that the service was under emergency circumstances, and (b) a description supporting the emergency status.  Remember, auditors will be scrutinizing any claim above and beyond the normal anesthesia service.

While traditional Medicare does not pay for qualifying circumstances, many commercial payers do.  According to the ASA’s 2018 annual Commercial Conversion Factor survey, approximately 85% of payers covered the qualifying circumstance codes.  However, some commercial payers no longer reimburse for these services, Cigna and United Healthcare being among them.  As such, it’s important that payment or nonpayment for these services be considered in your contract negotiations with private health plans.