Anesthesia Complicated By Hypothermia and Hypotension: A Fresh Look at Old Friends

Summary

The ASA Guide has been slightly revised with regard to the two codes listed below. We wanted to make sure everyone was aware.

The 2019 ASA Relative Value Guide(RVG) includes minor revisions for two codes that can be billed as adjunct services for an anesthetic. One, 99116, describes anesthesia complicated by the utilization of total body hypothermia, while the other, 99135, reflects the use of controlled hypotension. These codes have been part of the ASA guide for many years, but their usage has been noticeably inconsistent across the country. Such inconsistency raises three questions:

• Are many anesthesia providers simply unaware of these codes?
• Is there a failure to fully understand the criteria for applying such codes?

• Are providers not documenting/submitting these services due to doubts about reimbursement?

The treatment below will hopefully provide greater insight on when to submit, and how to document, the anesthesia "hypo" codes.

Hypothermia – 99116

This code has been part of the ASA's RVG since its inception. The original definition was "Anesthesia complicated by utilization of total body hypothermia." The 2019 version of this ASA resource contains a change that now allows this code to be billed in addition to a "without pump" service (CPT 00566). The RVG lists the basic value for 99116 as "5" units; however, insurance payments are based on a fee schedule, not ASA units. While Medicare and most Medicaid plans across the country do not reimburse this code, many commercial insurance plans do pay for this service. A survey recently undertaken revealed that 99116 is not widely used by our client base, and many have never billed for it. When it is billed, it is done primarily in conjunction with CABG and valve procedures.

Hypotension – 99135

This is the more commonly used of the two codes at issue. As previously noted, 99135 describes "Anesthesia complicated by utilization of controlled hypotension." It is commonly understood that the hypotension is medically induced and ultimately reversible. Again, the most recent RVG guidance indicates this code can now be used in association with CPT 00566. The unit value for the service is still listed as "5." Payment relative to this code can vary dramatically from plan to plan, as illustrated in the following section.

Payment Patterns

A review of claims for calendar year 2018 reveals that both codes were used, based on appropriate documentation. Many commercial plans reimbursed these codes, although there was a wide range in payment amounts. Now that each of these codes can be billed in tandem with the "without pump" anesthesia services, as reflected by CPT 00566, a new stream of revenue is suddenly available. Accordingly, providers should take a new look at these old codes!

Documentation Concerns

Specific documentation requirements for the use of these codes appear to be quite vague, which may partially explain their lack of use. A review of actual claim submissions indicates that 99116 has been used most commonly for CABG and valve procedures, while 99135 has been used typically for orthopedic procedures—particularly of the shoulder. As long as you are submitting these ancillary codes in conjunction with primary codes that do not preclude the usage of 99116 or 99135, i.e., 00562, 00563, 00567, you need to at least document the following language on the anesthesia record:

• For 99116: "Utilized total body hypothermia"
• For 99135: "Utilized controlled hypotension"

It needs to be documented that the service was performed at the surgeon's request.

You will want to leave no doubt for the payor auditor that you deserve reimbursement for these services; so, make your note clear and use the "magic words," i.e., the code descriptor language as found in the RVG.

Conclusion

It is not our place to question the appropriateness of our clients' clinical practices but rather to ensure that, where appropriate, such practices conform to the specific requirements as outlined in the CPT manual. Given the lack of specificity related to these two codes, one could reasonably presume that not all clients are optimizing these coding opportunities. We are here to bridge the information gap as it concerns these two services. If you have questions about the criteria for deliberate hypothermia and hypotension, please contact your account executive. Following a review of your practice parameters, in consultation with our Coding Department, your account executive will provide you specific data and recommendations relative to performance, documentation and submission of these services.

We want to hear from you. Do you have a topic you would like to see covered in an ABC eAlert? Please send your suggestions to info@anesthesiallc.com.