Field Avoidance and Special Positioning
According to Socrates, “Education is the kindling of a flame, not the filling of a vessel.” A thirst for knowledge by one who is new to the field can be just as important to an employer as an employee with years of experience—even more so if the experienced employee believes they know all there is to know. This is especially true about anesthesia billing—just when you think you have the rules down pat, something changes. Staying on top of your game requires constant learning, and the vessel will never be full. Knowledge is power and, literally, at our fingertips. Much of what one seeks to find can be accessed through search engines. Now it seems the hardest part of learning is an understanding of how to whittle down the vast amounts of data into just the information one needs.
Qualifying circumstances, including field avoidance and special positioning, are unique to anesthesia services. To capture these services, the coder must have an understanding of the services and when they may be reported. Field avoidance and special positioning are not specifically mentioned in the minimal section of Anesthesia Guidelines found in the Current Procedural Terminology® (CPT) Codebook, although they maybe considered as services under the Special Report section. These unique circumstances are defined by the American Society of Anesthesiologists’ Relative Value Guide®(ASA RVG) as “Any procedure around the head, neck, or shoulder girdle, requiring field avoidance, or any procedure requiring a position other than supine or lithotomy,” and have “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 definition includes a minimum base value of five units, this automatically excludes reporting with anesthesia services having a base value of five or more units. As there are eighty-three codes with a base value of fewer than five units, there is a good chance your anesthesia providers will qualify for additional payment for some of their anesthesia services, providing the documentation supports the reported circumstance.
For special positioning, surgeries performed in either the supine (patient is lying on their back) or lithotomy (patient is on their back with the hips and knees flexed and the thighs apart) are also excluded. Coders should be watchful for any other position documented, particularly if the patient is morbidly obese, and remember to check whether the anesthesia base value is less than five (5) units. According to Anesthesia & Pain Coder’s Pink Sheet, a study of positioning found that the reverse Trendelenberg was the optimal position for morbidly obese patients.
Field avoidance indicates that the anesthesia provider does not have access
to the patient’s airway during surgery. This may be due to the nature of the case (i.e., 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 the anesthesia provider.
Qualifying circumstances, which include field avoidance and special positioning, are not services covered by the Centers for Medicare and Medicaid Services (CMS) Medicare Administrative Contractors (MACs), even though these exclusions are not mentioned in the Payment for Anesthesiology Services section of the 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 relevant example, one may use other anesthesia qualifying circumstances, such as CPT 99100 (Anesthesia for patient of extreme age, younger than 1 year and older than 70) to determine whether these services have a “B” or bundled status with anesthesia services. CGS Administrators includes anesthesia qualifying circumstances under Status B codes in the publication Bundled, Inactive and Non-Payable Codes for 2014: Medicare Physician Fee Schedule Data Base and 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 important to understand that even though Medicare does not cover qualifying circumstances, this is not always true for Medicaid programs, which vary by state. For example, the Medicaid program for California, MediCal, allows additional payment for anesthesia procedures complicated by unusual position or surgical field avoidance when identified with a -22 modifier to indicate increased procedural services.
Commercial insurance policies often recognize the value of these services, although the reporting processes may differ. 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.” 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. Remember the adage “if it wasn’t documented it wasn’t done?” Coders cannot capture billable services that are not indicated on the anesthesia record, even if they are marked on an internal billing sheet. Billing sheets are not usually considered as part of the patient’s medical records. There is no universal anesthesia record and a typical anesthesia billing company sees many different records, so coders must determine where on each record the anesthesia providers document these types of services, which can be quite challenging with paper records and handwritten notes. It is also difficult if the anesthesia providers are using stick figures to draw the patient’s position on a paper anesthesia record. Sometimes the coders can’t tell whether the feet are up (supine) or down (prone). With a paper record, the clearest way to document is 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 to document qualifying circumstances. If the EAR doesn’t have a field summary, look within the body or comments section. Learn where qualifying circumstances information is documented in your practice.
Specific anesthesia policy and anesthesia billing rules are often non-existent or difficult to find. If a policy is found, and doesn’t address qualifying circumstances, they should be reported. If no policy is found, they should be reported. If they are denied, contact the insurance company to determine the reason. If an appeal is necessary, the best way to help an insurance company understand the value of the service is to be able to explain why the services have a higher value. Coders, regardless of the length of their experience, are continuously learning—one of the constants of the coding industry is change. Excellent coders are invaluable—they ask questions and look for answers.
References:
- BC/BS of Hawaii
- http://www.hmsa.com/PORTAL/PROVIDER/zav_pel.ph.ANE.900.htm
- CGS Administrators, LLC, Bundled, Inactive and Non-Payable Codes for 2014
- http://www.cgsmedicare.com/pdf/J15_FeeSchedules2014.pdf
- Medi-Cal
- http://files.medi-cal.ca.gov/pubsdoco/newsroom/newsroom_11675_3.asp
- 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
- Positioning Resources
- http://www.openanesthesia.org/Patient_Positioning_and_Injury
- http://commons.wikimedia.org/wiki/File:Supine_position_2012-02-02.jpg
- http://commons.wikimedia.org/wiki/File:Lithotomy_position_01.jpg
- http://www.medtrng.com/posturesdirection.htm
- http://www.aaos.org/news/aaosnow/jan13/managing7.asp
- http://en.wikipedia.org/wiki/Surgical_positions
- http://commons.wikimedia.org/wiki/File:Reverse_trendelenburg_position_01.gif