February 24, 2020

There are two little-used codes in the ASA Relative Value Guide (RVG) that may warrant a bit more attention than they presently get.  Specifically, we’re talking about 99116 for total body hypothermia and 99135 for controlled hypotension.  Over the years, we have found that very few of our clients actually utilize, or at least document, these services.  Is this because they don’t know when or how they apply, or because the anesthesia techniques they refer to are no longer applicable?  Is it possible that the coding rules have changed so as to limit the unbundling of these services?  Whatever the reason for the meager reporting of hypothermia and hypotension services by anesthesia providers, we thought it might be time to take a second look.

The Codes in Question

The ASA’s RVG provides the following descriptor for each of these codes:

99116 – Anesthesia complicated by utilization of total body hypothermia (List separately in addition to code for primary anesthesia procedure) (RVG Comment: Do not report in conjunction with codes 00562, 00563, 00567) – 5 base units

99135 – Anesthesia complicated by utilization of controlled hypotension (List separately in addition to code for primary anesthesia procedure) (RVG Comment: Do not report in conjunction with codes 00562, 00563, 00567) – 5 base units

These seem straightforward enough, but do providers know what’s expected to actually meet the threshold for payment for each of these services?  In the following section, we will provide further insight on meeting the requirements for submitting these services for reimbursement. 

Hypothermia: Requirements for Reimbursement

From a clinical and documentation standpoint, 99116 would require the following:

1. During a procedure in which an anesthesiologist or anesthetist administers anesthesia to the patient, the provider induces hypothermia in the patient, affecting the complexity of the anesthesia service. The provider most commonly induces hypothermia during intracranial surgeries.
2. The provider must document the inducing of the hypothermic state at the time of the provision of the anesthesia service in order to support the submission of 99116.
3. Examples of the kind of documentary support for this service that we’re looking for on the anesthesia record include: “hypothermic state induced per surgeon's request,” “surgeon’s request for hypothermia initiated,” or “temperature reduced to 34.5 degrees C per surgeon request.”

Hypotension: Requirements for Reimbursement

To bill for 99135, the following should be noted:

1. During a procedure in which an anesthesia provider administers anesthesia to the patient, the anesthesia provider maintains controlled hypotension, monitoring the patient's blood pressure while it drops drastically and then levels off.
2. The provider must document the inducing of the controlled hypotension at the time he/she provides the anesthesia service to support using this code.
3. Some practices have an internal policy that an arterial line must be used to justify controlled hypotension, but this is not the official position of any payer or plan that we have identified.
4. When documenting this service, providers need to list: “Hypotension per surgeon’s request.”

When A Payer Doesn’t Pay

When coders receive charge documents indicating that either of these services was performed, they will code for them irrespective of the patient’s insurance plan.  It is one of the inherent challenges in anesthesia billing that coders try to identify all aspects of care that may be billable.  Our billing program, F1RSTAnesthesia, then sorts through each code to determine whether it can be submitted to a given payer.  The best example of this is physical status (PS). When PS III, IV or V is indicated on the record, it will be entered on the claim, even though many insurance plans, such as Medicare, do not recognize it.  In these cases, we simply flag it for tracking purposes only.

When it comes to codes 99116 and 99135, there are actually multiple issues to consider.  The CPT manual specifically precludes the use of these codes with certain cardiac procedures. So, even though our coders will capture these services for tracking purposes relative to CABGs or valve cases, they will not be submitted for payment. Then, there is the matter of the patient’s insurance, which is state- or plan-specific.  If a payer does not reimburse hypothermia or hypotension, our billing system will automatically suppress these codes from going out on the claim.

A Drop in the Bucket?

While it is true that clients who use these services are able to generate at least some revenue via the submission of these codes, the percentage of paid hypothermia and hypotension charges is quite small.  Furthermore, while the RVG recommends these services be reimbursed at an additional 5 units, we rarely see payments reflecting these amounts.  May payers will go by a pre-formulated fee schedule that pays considerably less.  Clearly, the use of these codes is not a huge revenue generator for the practices that use them, but some will argue that every little bit helps as it concerns group reimbursement. If you have questions about your use of these codes, feel free to contact your account executive for a detailed analysis or reach out to us at info@anesthesiallc.com.

With best wishes,

Tony Mira
President and CEO