(For all benefit plans)
As required by the Centers for Medicare & Medicaid Services (CMS), anesthesia claims must include one of the modifiers listed below when a physician or a certified registered nurse anesthesiologist (CRNA) administers anesthesia. Anesthesia claims that do not include these modifiers will be denied. You may not have been required to enter these modifiers on your anesthesia claims in the past, but we encourage you to do so to comply with CMS requirements.
|AA||Anesthesia services performed personally by the anesthesiologist.|
|AD||Medical supervision by a physician; more than four concurrent anesthesia procedures.|
|G8||Monitored anesthesia care for deep complex, complicated or markedly invasive surgical procedures.|
|G9||Monitored anesthesia care for a patient who has a history of severe cardiopulmonary condition.|
|QK||Medical direction of two, three or four concurrent anesthesia procedures involving qualified individuals.|
|QS||Monitored anesthesia care service; providers must report actual anesthesia time on the claim.|
|QX||CRNA service with medical direction by a physician.|
|QY||Medical direction of one certified registered nurse anesthetist by an anesthesiologist.|
|QZ||CRNA service; without medical direction by a physician.|
|GC||These services have been performed by a resident under the direction of a teaching physician. One of the above payment modifiers must be used in conjunction with the GC modifier.|
Modifiers for Services and Procedures During the Postoperative Period
Many services required of a physician following an initial procedure, including additional medical or surgical interventions, are included in the assigned global period. Such services are not eligible for separate reimbursement. These services, if billed separately, will be denied as being included in the global surgical package. The following are exceptions, indicated by the use of the appropriate code modifier:
- Use modifier 58 to report a staged or related procedure or service performed by the same physician during the postoperative period of the initial procedure. Use modifier 58 to report a staged procedure that is planned prospectively at the time of the initial procedure, a staged or related procedure that is more extensive than the original procedure, or to report therapy following diagnostic surgery.
- Use modifier 78 to report a procedure rendered during the postoperative period as an unplanned return to the operating/procedure room for a related procedure following the initial procedure. Modifier 78 applies if the unplanned procedure is rendered by the same physician (or the same specialty physician from the same group). Procedures or services not rendered in an operating room or procedure room setting are included in the global surgery period; using modifier 78 is not appropriate.
- Use modifier 79 to report an unrelated procedure or service by the same physician (or the same specialty physician from the same group) during the postoperative period. The billed ICD-9 codes should support the procedure's status as unrelated to the initial procedure(s). Using modifier 79 for procedures relating to the original surgery is not appropriate.
Matching Revenue Codes with HCPCS Codes
Outpatient services require both a HCPCS code and a revenue code that must correspond.
Submission of Claims Spreadsheets for Review
Requests for adjustments to previously processed claims are occasionally submitted using an Excel spreadsheet. When submitting such requests, please include the original claim number with the other relevant claim details, e.g., member/patient name, ID number and date of birth, date(s) of service, total charges and the expected adjusted amount.
If you do not have the original claim number, having the data elements listed below will assist us in quickly locating your original claim in our system. Please make every effort to ensure the following information is provided:
|For Professional Services||For Facility Services|
|Member ID||Member ID|
|Provider License||Provider License|
|Date(s) of Service||Date(s) of Service|
|Modifiers (to account for bilateral and repeat procedures)|