Anesthesia Modifiers - P1 - P6 modifier

Anesthesia Modifiers Including Physical Status Modifiers:

All anesthesia services are reported by use of the anesthesia five-digit procedure code (00100-01999) plus the addition of a physical status modifier. The use of other optional modifiers may be appropriate.

Physical Status Modifiers

Physical Status modifiers are represented by the initial letter 'P' followed by a single digit from 1 to 6 defined below:

P1 - A normal healthy patient.

P2 - A patient with mild systemic disease.

P3 - A patient with severe systemic disease.

P4 - A patient with severe systemic disease that is a constant threat to life.

P5 - A moribund patient who is not expected to survive without the operation.

P6 - A declared brain-dead patient whose organs are being removed for donor purposes.

The above six levels are consistent with the American Society of Anesthesiologists (ASA) ranking of patient physical status. Physical status is included in CPT to distinguish between various levels of complexity of the anesthesia service provided.

Example: 00100-P1

Other Modifiers (Optional) Under certain circumstances, medical services and procedures may need to be further modified. Other modifiers commonly used in Anesthesia are included below. A complete list of modifiers and their respective codes are listed in Appendix A.

-22 Unusual Procedural Services: When the service(s) provided is greater than that usually required for the listed procedure, it may be identified by adding modifier '-22' to the usual procedure number or by use of the separate five digit modifier code 09922. A report may also be appropriate.

-23 Unusual Anesthesia: Occasionally, a procedure which usually requires either no anesthesia or local anesthesia, because of unusual circumstances must be done under general anesthesia. This circumstance may be reported by adding the modifier '-23' to the procedure code of the basic service or by use of the separate five digit modifier code 09923. 

Note: Modifier '-47', Anesthesia by Surgeon, (see modifier section) would not be used as a modifier for the anesthesia procedures 00100- 01999.

-32 Mandated Services: Services related to mandated consultation and/or related services (eg, PRO, 3rd party payer) may be identified by adding the modifier '-32' to the basic procedure, or the service may be reported by use of the five digit modifier 09932.

Anesthesia Modifiers - P1 - P6 modifier

Anesthesia Modifiers Including Physical Status Modifiers:

All anesthesia services are reported by use of the anesthesia five-digit procedure code (00100-01999) plus the addition of a physical status modifier. The use of other optional modifiers may be appropriate.

Physical Status Modifiers

Physical Status modifiers are represented by the initial letter 'P' followed by a single digit from 1 to 6 defined below:

P1 - A normal healthy patient.

P2 - A patient with mild systemic disease.

P3 - A patient with severe systemic disease.

P4 - A patient with severe systemic disease that is a constant threat to life.

P5 - A moribund patient who is not expected to survive without the operation.

P6 - A declared brain-dead patient whose organs are being removed for donor purposes.

The above six levels are consistent with the American Society of Anesthesiologists (ASA) ranking of patient physical status. Physical status is included in CPT to distinguish between various levels of complexity of the anesthesia service provided.

A report may also be appropriate.-23 Unusual Anesthesia: Occasionally, a procedure which usually requires either no anesthesia or local anesthesia, because of unusual circumstances must be done under general anesthesia. This circumstance may be reported by adding the modifier '-23' to the procedure code of the basic service or by use of the separate five digit modifier code 09923. 

Anesthesia Billing form Guidelines

Prior Authorization

Anesthesia itself does not require prior authorization; however, prior authorization may be required for the related surgical procedure or service.

Time-Based Units

During the first 4 hours of service, 15 minutes equals 1 unit. If services are provided for longer than 4 hours in one occurrence, each 10-minute period after the initial 4 hours equals 1 unit. A period less than a unit should be rounded up to the next unit.

Example A: 5 hours or 300 minutes equals 22 units – 16 units for the first 4 hours (1 unit per each 15 minutes) and 6 units for the last hour (1 unit per each 10 minutes).

Example B: 128 minutes is billed as 9 units (8 units for the first 120 minutes and 1 additional unit for the remaining 8 minutes).

Completing the Claim Form

· Field 19: When billing a time-based code,enter the total minutes of reportable anesthesia time in Field 19.

· Field 24D: On the bottom, white half of the claim line, enter one CPT code and one physical status modifier (P1-P6). List additional modifiers when appropriate

· Field 24G:

o When using a time-based code, enter the number of reportable anesthesia time units; do not add base units or modifier units to the time units.

o When using an occurrence-based code, enter a “1” for each occurrence. The following codes are paid per occurrence: 01953, 01967, 01968, 01969, 01996, 99100, 99116, 99135 and 99140.

CPT Code 99140 Medicaid carefully monitors for the appropriate use of code 99140 and modifiers P3, P4 and P5. Providers’ in-office records must verify medical necessity of this procedure.

Code 99140 should be used only for emergency conditions. This does not include a normal delivery or use of an epidural during delivery.

Anesthesia services: general, local, regional, epidural:

• We do not provide separate or additional reimbursement for the usual monitoring procedures that are traditionally part of and recorded on the anesthesia record because they are considered an integral part of anesthesia services and are included in the anesthesia base unit value. Unusual forms of monitoring (eg, intra-arterial, central venous and Swan-Ganz) are not included and may be billed separately.

• We do not provide separate or additional reimbursement for local anesthesia because it is considered part of the surgical procedure or other manipulation for which it is given.

• Moderate sedation services provided by the same physician performing the diagnostic or therapeutic service that the sedation supports should be reported with CPT codes 99143-99145.

Separate or additional reimbursement for moderate sedation services submitted with codes 99143-99145 is allowed according to CPT coding guidelines and should be reported only with those procedures not listed in Appendix G of the CPT. Appendix G, Summary of CPT Codes That Include Moderate (Conscious) Sedation, lists those procedures for which conscious sedation is an inherent part of the procedure itself.

• Reimbursement consists of anesthesia base units plus anesthesia time units multiplied by a conversion factor.

• 99100: anesthesia for patient of extreme age, under one year and over seventy.

• 99116: anesthesia complicated by utilization of total body hypothermia.

• 99135: anesthesia complicated by utilization of controlled hypotension.

• 99140: anesthesia complicated by emergency conditions (specify).

• 99143: Moderate sedation services (other than those services described by codes 00100-01999) provided by the same physician performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; under 5 years of age, first 30 minutes intraservice time

• We do not provide separate reimbursement for postoperative epidural narcotic analgesia when performed on the same date of service as epidural anesthesia, since the primary reason for the catheter insertion is for the administration of the anesthetic. 

However, we do provide payment for daily hospital management under CPT code 01996 on the same day as when epidural anesthesia is administered for the surgical procedure.

• We do not provide separate reimbursement to an anesthesiologist for postoperative pain consultation when performed on the same date of service as the surgical procedure because usual pain management services are considered part of postoperative care and included in the anesthesia base units.

• We reimburse postoperative patient-controlled analgesia (PCA) only as an initial consultation when performed subsequent to the day of surgery. Report initial consultation (CPT code 99252), 1 unit of service only. Report CPT code 99252 only once during a hospital admission.

• Reimbursement for a pre-operative consultation that is rendered within one to ten days prior to the date of surgery is already included in the global allowance for the administration of anesthesia. 

However, if an interval exceeding ten days elapses between a routine pre-operative consultation and the date of surgery, due to surgical rescheduling or cancellation, then the initial pre-operative evaluation can be reimbursed as a limited consultation.

• Bill a single epidural injection of narcotics using CPT code 62310 or 62311 and 1 unit of service.

• Bill an epidural catheter insertion for the continuous administration of narcotics using CPT code 62318 or 62319 and 1 unit of service.

• Effective 01/01/04 according to CPT 2004, CPT code 01996 to report daily hospital management of continuous epidural or subarachnoid drug administration performed after insertion of an epidural or subarachnoid catheter.

• Do not bill CPT codes 62310-62319 on the day of surgery when the epidural injection is performed primarily for the surgical anesthetic and not for the postoperative narcotic. CPT code 01996 (daily hospital management) may be billed if the record demonstrates that the anesthesiologists’ administration of the agent required patient care substantially beyond the intraoperative and normal recovery period.

• Do not bill 01996 (daily hospital management) on the same date of service as 62310 – 62319.

• Bill anesthesia for electroconvulsive therapy (ECT) with CPT code 00104. One unit of service is allowed.

• Bill for Swan-Ganz catheter insertion using CPT code 93503.

• Bill the insertion of epidural or intrathecal catheter for narcotic infusion for intractable pain due to malignant disease requiring laminectomy with CPT code 62351 and without laminectomy with CPT code 62350. 

ANESTHESIA FOR OBSTETRIC SERVICES - CPT 01960, 01967 - 01969

Delivery only codes:

• CPT code 01960 for anesthesia for vaginal delivery only.

• CPT code 01961 for anesthesia for cesarean delivery only. Labor analgesia/anesthesia for vaginal or cesarean delivery codes:

• CPT code 01967 for neuraxial labor analgesia/anesthesia for planned vaginal delivery (List separately in addition to code for primary procedure performed).

Effective 9/1/04, we allow a maximum of 20 time units for CPT code 01967.

• CPT code 01968 for anesthesia for cesarean delivery following neuraxial labor analgesia/anesthesia (List separately in addition to code for primary procedure performed). Bill CPT 01968 in conjunction with CPT code 01967

Other codes:

• CPT code 01962 for anesthesia for urgent hysterectomy following delivery.

• CPT code 01963 for anesthesia for cesarean hysterectomy without any labor analgesia/anesthesia care.

• CPT code 01964 for anesthesia for abortion procedures.

• CPT code 01969 for anesthesia for cesarean hysterectomy following neuraxial labor analgesia/anesthesia (List separately in addition to code for primary procedure performed).