Modifying circumstances representative of age, emergency, total body hypothermia, and controlled hypotension should be reported under procedure codes 99100, 99116, 99135 and 99140. These procedures are not associated with numbers of units. They will be reimbursed at a flat fee. The following guidelines should be used:

1. Age - 99100

   Payment may be allowed for a patient of extreme age, under one year and over 70.

2. Emergency - 99140

   Payment may be made for any service reported as an "emergency," except for a normal vaginal delivery.

3. Other Modifying Codes

   Payment may be allowed when the doctor requests one of the following:
   

   1. Utilization of total body hypothermia - 99116
   2. Utilization of controlled hypotension - 99135
      
   
   
4. Physical Status Units - Physical status should be reported under the appropriate modifier (P1-P6).

   Physical Status I (Modfier P1) - A normally healthy patient. There is no organic, physiologic, biochemical, or psychiatric disturbance. The pathological process for which the operation is to be performed is localized and not conducive to systemic disturbance.
   Units allowed - 0

   Physical Status II (Modifier P2) - A patient with mild to moderate systemic disturbance caused either by the condition to be treated surgically or by other pathophysiologic processes.
   Units allowed - 0

   Example: Classes 1 and 2a of the heart classification:
   

   Class 1 - Patients with organic heart disease, able to carry on ordinary physical activity without discomfort. Ordinary activity does not cause undue fatigue, palpitation, dyspnea or chest pain.

   Class 2a - Patient unable to carry on ordinary physical activity without discomfort, activity slightly limited. Ordinary activity causes undue fatigue, palpitation, dyspnea or chest pain, but patients rarely show signs of cardiac insufficiency or signs of infection. Mild diabetes, essential hypertension, anemia, perhaps extreme obesity or chronic bronchitis.
   

   Physical Status III (Modifier P3) - A patient with severe systemic disease.
   Units allowed - 1

   Example:
   

   Class 2b of the heart classification in which activity is greatly limited, less than ordinary physical activity causes undue fatigue palpitation, dyspnea or chest pain and patient shows one or more signs of cardiac insufficiency, anginal syndrome or signs of infection.
   

   Physical Status IV (Modifier P4) - A patient with severe systemic disorder already life threatening and not always correctable by operative procedures. Units allowed - 2

   Example:
   

   Class 3 of the heart classifications involving patient with organic heart disease and with signs or symptoms of cardiac insufficiency at rest, unable to carry out any physical activity without discomfort. These patients show marked angina syndrome or signs of active cardiac infection.

   Advanced degrees of pulmonary, hepatic, renal, or hormonal insufficiency.
   

   Physical Status V (Modifier P5) A moribund patient who has little chance of survival but is submitted to operation in desperation. This classification is rarely used. Units allowed - 3

   Example:
   

   A ruptured aneurysm, with the patient in profound shock; major cerebral trauma with rapidly increasing intracranial pressure; massive pulmonary embolus.
   

   Physical Status VI (Modifier P6) - A declared brain-dead patient whose organs are being removed for donor purposes. Units allowed - 0

   If the doctor reports physical status III, IV, or V, payment may be allowed for the units listed above. If the doctor does not report physical status, no additional units will be allowed.

5. Position Units

   No allowance should be made routinely for position. A claim should be referred to a professional consultant for individual consideration if there are extenuating circumstances reported in connection with the position of a patient.

   Up to and including four (4) additional modifying units may be allowed when the anesthesiologist requests additional units for general anesthesia for congenital cataract extraction.

Description

Modifying units represent those circumstances that necessitate skills of a physician beyond those usually required.