Physical status modifiers (PS)
(Priority Health accepts these modifiers, but they do not affect payment)
- 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 removed for donor purposes
Modifiers
- 22: Unusual Procedure/Service: use the Explanation form
- 23: Unusual Anesthesia (Usually done under local but requires general)
- 32: Mandated Services (Related to mandated consult or service)
- 47: Anesthesia by Surgeon (Attached to the appropriate surgery code)
- 51: Multiple Procedures
- 53: Discontinued Procedures
- 59: Distinct Procedural Service
- 78: Unplanned Return to the Operating/Procedure Room by the Same Physician or Other Qualified Health Care Professional following Initial Procedure for a Related Procedure During the Postoperative Period
The use of anesthesia modifiers, when the CPT code isn't fully descriptive, is required as follows:
- G8 anesthesia modifier – Used to indicate certain deep, complex, complicated or markedly invasive surgical procedures. This modifier is to be applied to the following anesthesia codes only: 00100, 00300, 00400, 00160, 00532 and 00920.
- G9 anesthesia modifier – Represents “a history of severe cardiopulmonary disease” and should be used whenever the provider feels the need for monitored anesthesia care due to a history of advanced cardiopulmonary disease. The documentation of this clinical decision-making process and the need for additional monitoring must be clearly documented in the medical record.
HCPCS Level II modifiers
When related anesthesia services are billed by a CRNA and an anesthesiologist (for medical direction/oversight), the fee is split and each are reimbursed at 50%.
- AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
- QB: Physician provided service in a rural HPSA
- QK: Medical direction of two, three or four concurrent anesthesia procedures involving qualified individuals
- QS: Monitored anesthesia care service (MAC)
- QX: CRNA service: with medical direction by a physician
- QY: Medical direction of one CRNA by an anesthesiologist
- QZ: CRNA service: without medical direction by a physician (CRNA paid at 100%)
Residents performing anesthesia services
- Services should be reported under a supervising anesthesiologist
- GC modifier should be coded to indicate services were performed in part by a resident under the direction of a teaching physician
- AA modifier should be coded to indicate anesthesia services were performed personally by anesthesiologist
If medical direction is provided to more than one case, the appropriate modifier for multiple case oversight should be utilized.
Priority Health follows CMS's teaching physician guidelines. These should be clearly documented and detailed in the medical record.