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Adding Value for Special Circumstances: Field Avoidance and Special Positioning

Kelly D. Dennis, MBA, ACS-AN, CANPC, CHCA, CPC, CPC-I
Perfect Office Solutions, Inc., Leesburg, FL

In coding and billing for anesthesia services, it often seems that just when you think you understand the rules, something changes.

One area of anesthesia billing that consistently confuses practices and coding professionals is the ability to add value for special circumstances. Qualifying circumstances, including field avoidance and special positioning, are unique to anesthesia services. To capture these services, your coding team must understand what the services are as well as how and when they may be reported.

Field avoidance and special positioning are not mentioned in the minimal section of Anesthesia Guidelines found in the Current Procedural Terminology® (CPT) code set, although they may be considered as services under the Special Report section. These circumstances are defined by the American Society of Anesthesiologists (ASA) as "Any procedure around the head, neck, or shoulder girdle, requiring field avoidance, or any procedure requiring a position other than supine or lithotomy, that has a minimum base value of 5, regardless of any lesser base value assigned to such procedure in the body of the Relative Value Guide®."

Since the ASA definition includes a minimum base value of five units, this automatically excludesreporting with anesthesia services having a base value of five or more units. As there are approximately 85 anesthesia codes with a base value of five units or less, there is a good chance your anesthesia providers will qualify for additional payment for some of their anesthesia services, providing documentation supports the reported circumstance. Keep in mind that other carriers may have definitions that vary. For example, Medi-Cal, the Medicaid carrier for California, may only allow these circumstances when the procedure has a base value of three units.

For special positioning, surgeries performed in either the supine or lithotomy positions are excluded. However, coders should be watchful for any other position documented and remember to check whether the anesthesia base value is less than five units.

Field avoidance indicates the anesthesia provider does not have access to the patient's airway during surgery. This may be due to the nature of the case (e.g., face or shoulder surgery) or because the surgeon has the patient in a different position.

Both field avoidance and unusual positioning make the case a higher risk for the patient and more difficult for the anesthesia provider. Qualifying circumstances, which include both field avoidance and special positioning, are not services covered by the Centers for Medicare and Medicaid Services (CMS) Medicare Administrative Contractors (MACs), although these exclusions are not mentioned in the Payment for Anesthesiology Services section of Medicare Claims Processing Manual Chapter 12 - Physicians/Nonphysician Practitioners (Section 50).

As an added difficulty, there are no specific procedure codes or modifiers to describe field avoidance and special positioning. To find a relative example, one may use other anesthesia qualifying circumstances, such as CPT 99100 (Anesthesia for patient of extreme age, younger than one year and older than 70), to determine these services have a "B" or bundled status with anesthesia services. CGS Administrators, LLC includes anesthesia qualifying circumstances under Status B codes in the publication Bundled, Inactive and Non-Payable Codes for 2015: Medicare Physician Fee Schedule Data Baseand indicates "Payment for these services is always included in payment for other services not specified. There are no RVUs [relative value units] or payment amounts for these codes, and separate payment is not made."

However, it is important to understand that even though traditional Medicare does not cover qualifying circumstances, this is not always true for Medicaid programs, which vary by state. For example, Medi-Cal allows additional payment for anesthesia procedures complicated by unusual position or surgical field avoidance when identified with a 22 modifier to indicate the increased procedural services. Commercial insurance policies often recognize the value of these services, although the reporting processes may differ.

Last revised in 2011, the policy of Blue Cross Blue Shield of Hawaii requires the use of a 23 modifier (unusual anesthesia) and specifies it "should be used to indicate anesthesia services complicated by procedures performed in the prone position or by field avoidance." The policy also specifies which CPT codes may be reported and differs from the ASA recommendations, allowing a unit value of one.

If carrier policy does not define whether qualifying circumstances are covered, they should be billed and reported. No policy will cover unbilled or unreported services! Unless otherwise specified, coders may report either of these circumstances with a 22 modifier and "field avoidance" or "xxx position" in box 19 or the electronic equivalent.

It is helpful for anesthesia providers to understand that qualifying services may be missed if they are not clearly documented, and it is helpful for coders to understand when these services might be performed and how they are documented. Coders cannot capture billable services that are not indicated on the anesthesia record, even if they are marked on an internal billing sheet, as billing sheets are not usually considered part of the patient's medical record.

As there is no universal anesthesia record and a typical anesthesia billing company sees many different records, coders must determine where on each record the anesthesia providers document these types of services. This can be challenging with paper records and handwritten notes. It is also difficult if the anesthesia providers use stick figures to draw the patient's position. Sometimes the coders can't tell whether the feet are supine or prone.

With a paper record, the clearest way to document is with a legible note in the remarks or comments section. Electronic anesthesia records (EARs) are much easier to read and may have a field summary that includes an area in which to document qualifying circumstances. If the EAR doesn't have a field summary, coders should look within the body or comments section. It is important for coding professionals to know where qualifying circumstances information is documented in your practice.

Specific anesthesia policy and anesthesia billing rules are often difficult to find. If a policy is found that doesn't address qualifying circumstances, it should be reported. If no policy is found, it should be reported. If claims are denied, the insurance company should be contacted to determine the reason. If an appeal is necessary, the best way to help an insurance company understand the value of the service is for the coding team to be prepared to explain why the services have a higher value and to include information provided by the ASA or other reputable resources.

Regardless of the depth and length of their experience, your coding staff will continue to encounter challenges such as these. The best way to support them is to encourage them to ask questions and scour all available resources for answers.

Resources

CGS Administrators, LLC (most current), 2015 Bundled, Inactive, and Non-Payable Codes for 2015

https://cgsmedicare.com/pdf/j15_fee_schedules_2015.pdf

HMSA Provider Resource Center, Anesthesia with Prone Position or Field Avoidance

https://hmsa.com/portal/PROVIDER/zav_pel.ph.ANE.900.htm

Medi-Cal

http://www.partnershiphp.org/Providers/Policies/Documents/Claims/Medi-Cal_Section%203.Subsection%20X.A.pdf

https://files.medi-cal.ca.gov/pubsdoco/publications/masters-mtp/part2/anestcms_m00.doc

Medicare Claims Processing Manual Chapter 12 - Physicians/Nonphysician Practitioners

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c12.pdf

Kelly D. Dennis, MBA, ACS-AN, CANPC, CHCA, CPC, CPC-I, has 35 years of experience in anesthesia and speaks about anesthesia issues nationally. She has a Master's Degree in Business Administration, is certified through the American Academy of Professional Coders, is an Advanced Coding Specialist for the Board of Medical Specialty Coding and serves as lead advisor for their anesthesia board. She is also a certified healthcare auditor and has owned her own consulting company, Perfect Office Solutions, Inc., since 2001. She can be reached at kellyddennis@attglobal.net.

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