The ABCs of Qualifying Circumstances

qualifying circumstances

Modifier codes are sometimes used to signal abnormal circumstances related to anesthesia care. These 5-digit qualifying circumstances codes are recognized as modifiers when they are billed as separate line items in order to report services that were provided under unusually difficult circumstances (i.e. unique operative conditions, extenuating issues with the patient’s condition, etc.).

Read on to learn what these codes are and how to properly use them as modifiers.

Qualifying Circumstances Modifiers for Anesthesia Risk

The following codes are recognized as anesthesia modifiers when reported properly.

99100 – Unit value = 1

Administration of anesthesia to a patient who is younger than age 1 or older than age 70.

99116 – Unit value = 5

Administration of anesthesia complicated by utilization of total-body hypothermia.

99135 – Unit value = 5

Administration of anesthesia complicated by utilization of controlled hypotension.

99140 – Unit value = 2

Administration of anesthesia complicated by emergency conditions only. An “emergency” is defined as delay in treatment of the patient that would lead to a significantly heightened increase in the threat to life or body part.

One thing of note is that if multiple anesthesia risk modifiers are billed, payment will be made as far up as the highest unit value modifier. When billed in conjunction with a Physical Status Modifier of equal unit value, no payment is allowed to the Qualifying Circumstances Modifier.

How to Document

For CPT codes 99116 and 99135, anesthesia records should be submitted. For CPT code 99140, the indications for performing the service should be recorded directly on the CMS 1500 claim form. Block 19 may be used to record risk indications, and EMC providers can enter indications in the Comments field.

Filing a Claim

When using an anesthesia risk modifier, the anesthesiologist may use Block 19 for provide indications or supporting information. Anesthesia risk modifiers may be reported in Block 24D of the CMS 1500 claim form. Enter the applicable anesthesia CPT code on the first line, followed by modifier codes. Then, report the charge for the service on the same line in box 24F, and put the time units in box 24G.

For situations that require the use of an anesthesia risk modifier, enter the 5-digit risk modifier code on the second line and report the charge for the modifier on the same line in box 24F.

MBM Can Handle Your Claims

If you’d rather focus on your practice and your patients than CPT codes, contact Medical Business Management to see how we can help. We specialize in anesthesia and pain billing, and we’re ready to take coding and billing off your plate. Contact us today!