Changelog

What you will see

A labor epidural line (01967) bills the directed or teaching modifiers only when the record shows that an anesthesiologist was there for the epidural. The autocoder compares the time of the 01967 line with the documented time of each anesthesiologist on the case. This applies when a CRNA, an anesthesiologist assistant (AA), or a resident placed the epidural.

• The time of an anesthesiologist overlaps. The line bills the directed modifiers from your medical direction settings with that anesthesiologist, for example QK for the anesthesiologist and QX on the CRNA line. At a shift change, the night anesthesiologist who directed the epidural can be a different person from the day anesthesiologist who did the cesarean.
• The time of no anesthesiologist overlaps. The case gets one question. For a CRNA placer, the line bills your CRNA-alone setting (QZ with the shipped settings) until the direction is confirmed.
• An AA or a resident placed the epidural. An AA or a resident cannot bill without a directing or teaching anesthesiologist. So the line keeps the directed modifiers, and the coder decides.

For example: a CRNA places a labor epidural early in the morning, and the anesthesiologist's documented time starts at the cesarean delivery hours later. The 01967 line bills QZ, and the coder confirms whether the anesthesiologist directed the placement.

Alert changes

• Labor Epidural Direction Not Shown (new, ob_labor_epidural_direction_unverified). Reviewer: a coder. Type: Compliance, severity 8. It names the placer, the epidural time and the time of each anesthesiologist on the case, and asks whether an anesthesiologist medically directed the placement. In HANK Claim Maker, this Compliance alert pulls a coder by default. It is the one alert for the line: the CRNA-alone audit alert does not appear beside it.
• When your facility requires a directing anesthesiologist for every CRNA line (the hardstop CRNA-alone setting), the CRNA line bills no payment modifier while the question is open. The question then follows that setting: it is a Hardstop, severity 10, for your charge entry team.

In a sample of 2,336 recent fully automated anesthesia cases, 1.4% had a 01967 line, so this question can apply to at most 1.4% of such cases.

When no anesthesiologist has documented time at all, the existing missing-times alert asks instead, so the case gets one question, not two.

What to look out for

• Read the labor note. If an anesthesiologist directed the placement, bill the directed modifiers with that anesthesiologist. If not, keep the non-directed billing for a CRNA, or correct the line for an AA or a resident.
• An anesthesiologist who places the epidural never gets this question.
• Your organization can silence this alert or change who it asks. Your CRNA-alone setting decides what a CRNA placer bills while the question is open, and who gets the question. Ask your Hank representative.

See Obstetric Anesthesia and the Anesthesia Alert Reference.

What you will see

Some anesthesia claims bill one anesthesia code on two lines on purpose, one line for each provider:

• Supervised cases. The anesthesiologist line carries AD, and the anesthetist line carries QX.
• One-to-one directed cases. The anesthesiologist line carries QY, and the anesthetist line carries QX.
• Relief cases. Each anesthesiologist who took over the case gets a line with AA for the time that anesthesiologist covered.

Automated claim validation (ClaimCleaner) can read these two lines as a duplicate. The second validation check on an anesthesia claim now keeps both lines. Every provider line stays billed, and the claim records the removal that the autocoder did not apply. The kept line also receives the diagnosis and modifier corrections that validation made on the other line of the same anesthesia code. The payment modifiers stay as they are, because the two lines differ there on purpose.

For example: an anesthesiologist supervises five concurrent rooms, and a CRNA gives the anesthetic in one of them. The CRNA line with QX stays on the claim beside the anesthesiologist line with AD.

Alert changes

• ClaimCleaner Returned the Line With No Codes (Informational, severity 3). This alert does not appear for a provider line that the autocoder keeps. It still appears for each line when validation removes every line of the anesthesia code. In HANK Claim Maker, this Informational alert does not stop the case.

What to look out for

• On supervised, one-to-one directed and relief claims, expect both provider lines on the finished claim.
• A true duplicate line is still removed as before. When validation removes every line of an anesthesia code, for example because a different crosswalk code with more base units replaces it, the autocoder applies the removal to each line.
• The two provider lines of one anesthesia code carry the same diagnoses after validation.

A routine extreme-age add-on no longer raises an alert. Before this release, every claim that billed 99100 carried a review alert asking a coder to confirm the patient's age. The autocoder had already verified that age against the date of service. That alert is gone, and so is the alert for a 99100 the autocoder withheld. The decision is on the claim instead:

• A billed 99100 line states the age in its rationale. The rationale opens with "Extreme age verified on the date of service", then names the date of service and the exact age the rule used, for example "70 years 1 day".
• A withheld 99100 sits in the bundled procedures. The reason states why: the age on the date of service does not qualify, the anesthesia code already describes the age, or the age could not be verified.
• The extreme-age add-on is reported once per anesthetic. If the documentation produces more than one 99100, the first line bills and each further copy moves to the bundled procedures as a duplicate.

No alert when a payer class bundles the add-ons. Medicare bundles 99100, 99116, 99135, and 99140 into the base anesthesia code, and your configuration can list other payer classes that do the same. Those claims no longer carry an informational alert. The codes move to the bundled procedures, and the reason on each entry names the payer class that bundles it.

One new alert, for demographics that cannot both be right. If the patient's date of birth is later than the date of service, the claim now carries the Date of Birth Is After the Date of Service alert (HARDSTOP, severity 8), and the extreme-age add-on is withheld. Every date-anchored rule reads those two dates, so this is a demographics question, not an add-on question. The alert fires on every specialty.

A new option to review a 99140 that rests on weak evidence. The autocoder trusts a documented emergency and raises no alert for it. Your organization can now ask for a review of the weak cases only. With the Emergency Add-On 99140 Billed On Weak Documentation rule turned on (FINANCIAL, severity 5), a coder is asked when a billed 99140 cites documentation that shows neither a physical status with the E suffix nor a statement that a delay in treatment would significantly increase the threat to life or body part. The rule is off unless you ask for it. A record that reaches you only as handwriting still raises the handwritten emergency-status alert.

The 99116 and 99135 review alert reads more precisely. It now asks you to confirm the record documents deliberate total body hypothermia (99116) or deliberate controlled hypotension (99135) as an anesthetic technique. The cooling and the low blood pressure that come with cardiopulmonary bypass are not the same thing, and they do not support these codes.

Why: a review alert is a question for a human. When the autocoder has no question, it should record what it did and stay quiet. The extreme-age alert asked a coder to re-check arithmetic the autocoder had already verified against the ASA rule, on a large share of anesthesia cases. The payer-class alert reported a decision your own configuration had made.

Physical status modifiers (P1 to P6) now follow your facility setting exactly. If your facility turns physical status modifiers off, no P1 to P6 value reaches a claim line, no matter where it came from. Before this fix, a physical status value that the coding step placed on a code by itself could stay on the claim after the setting said no. When the autocoder removes such a value, it records the removal with the Physical Status Modifier Removed Per Facility Configuration alert (INFORMATIONAL, severity 2). The documented ASA status still shows on the claim when the record has one.

Two new checks protect facilities that do bill physical status. A P1 to P6 value can be on a claim when the record documents no ASA physical status. The Physical Status Modifier Without a Documented ASA Status alert (FINANCIAL, severity 5) then asks a coder to confirm the status. If the setting is off and a value still slips through, the Physical Status Modifier Present Although the Facility Disables Them alert (FINANCIAL, severity 5) reports it.

The extreme-age add-on 99100 is never reported with 00326, 00561, 00834, or 00836. These anesthesia codes already describe a patient younger than 1 year, and CPT does not allow 99100 with them. The autocoder now moves such a 99100 to the bundled procedures, with a reason that names the anesthesia code. No bypass modifier is added.

99100 is re-decided when the demographics arrive late. When the date of birth is missing at coding time and the automatic gap fill recovers it from the record, the autocoder runs the age test again. A patient who qualifies gets 99100 back on the billable lines. A patient the recovered date of birth disproves loses a 99100 that was billing: it moves to the bundled procedures with the reason. The code also stays bundled when the anesthesia code excludes it, when a facility rule withholds it, or when the payer class does not pay it. Before this fix the code stayed off the claim with no trace.

Configuration problems are now visible on the claim. A qualifying circumstance setting that cannot be read as written raises the Qualifying Circumstance Configuration Is Malformed alert (FINANCIAL, severity 5) and names the fault and the posture the autocoder applied. A processing rules setting that cannot be read raises the Processing Rules Could Not Be Read alert (HARDSTOP, severity 9). Every claim now records which facility configuration built it and which qualifying circumstance posture applied to its payer class.

Facility instructions now follow GI and OB cases. An additional coding instruction configured for the anesthesia lane now also applies when the autocoder handles the case as a GI or obstetric case. Before this fix the instruction was dropped on those cases.

What to look out for:

Teams that used the extreme-age alert as a prompt to review patient demographics will not see it any more. If you want a reviewer on every 99100, ask your Hank representative to turn the alert on for the rule that adds the code:

"processingRules": {
    "special_circumstances_99100": {
        "action": {
            "setBillable": true,
            "createHRE": true,
            "hreTag": "FINANCIAL",
            "hreSeverity": 4,
            "hreReviewerRole": "CODER",
            "hreTemplate": "99100 billed for an extreme-age patient - confirm the date of birth."
        }
    }
}

The same shape works on the 99140 rule. Give every key: the switch turns the alert on, and the other keys set the type, the severity, the suggested reviewer, and the text the reviewer reads.

Two more points. The "enabled" switch on the physical status rule is now ignored; only its value decides. If you set the value to false and also switched the rule off, the modifiers used to appear anyway. They now stop, which lowers the base units billed on P3 and higher. If you switched the rule off but left the value true, nothing changes. And if your reports counted the informational payer-class alert to find bundled add-ons, count the bundled procedures on the claim instead.