Anesthesia Coding Alert

Keeping track of modifiers can be confusing because some modifiers (such as - 58, -78 and-79) primarily may be used for pain management while others are for anesthesia services. Taking the time to learn about the different modifiers and ensuring that youre using the correct ones in the right situations is key to correct payment.

Pain Management or Anesthesia Services

Most modifiers that apply to anesthesia can be divided into two groups, according to Mark DiDonato, manager of practice activities in the department of anesthesiology at Thomas Jefferson University Hospital in Philadelphia. Several of them are primarily used in association with pain management services, and the others are used in conjunction with anesthesia services for surgery.

Based on these groupings, coding may vary by carrier or by state, so check your local guidelines. Appendix A (pages 455-460) of CPT 2000 provides definitions and instructions for each modifier. Below is an outline of the most commonly used anesthesia pain services modifiers with examples and typical situations.

Pain Services Modifiers

Modifier -22 (unusual procedural services): Use this modifier when an anesthesiologist provides services that are greater than what is usually offered for a procedure. For instance, it would be appropriate to use it for CT scans or MRIs on infants or handicapped individuals, or a nerve block or injection that required several attempts.

Modifier -25 (significant, separately identifiable evaluation and management service by same physician on same day of the procedure or other service): Use in conjunction with pain procedures, such as a patient who is referred to an anesthesiologist for a nerve block. The physician conducts a history, physical and medical decision making (components of an evaluation/management [E/M] visit) to be sure that the patient is a good candidate for the procedure and will be able to tolerate it well. The E/M visit (99###-99###) would be coded with the -25 modifier if the nerve block is done on the same day. The E/M visit also can be performed later (in a different session) on the same day. This might happen if a postoperative block did not work and the patient needs to be evaluated for a different type of pain management regimen.

Modifier -26 (professional component): Certain procedures such as fluoroscopy and tracheoesophageal echo are combinations of a physician and technical component. This modifier is used to document the professional component of a service when the physician does not own the equipment. For example, an anesthesiologist performs an epidural steroid injection (ESI) under fluoroscopy, but the hospital owns the fluoroscopy equipment. He or she would bill for the ESI (62311, injection, single [not via indwelling catheter], not including neurolytic substances, with or without contrast [for either localization or epidurography], of diagnostic or therapeutic substance[s] [including anesthetic, antispasmodic, opioid, steroid, other solution], epidural or subarachnoid; lumbar, sacral [caudal]) and the fluoroscope (76000-26, fluoroscopy [separate procedure], up to one hour physician time, other than 71023 or 71034 [e.g., cardiac fluoroscopy]), using the -26 modifier to indicate that this was the professional component only. The anesthesiologist receives the professional part of the global payment, and the hospital receives the technical part of the global payment for the procedure.

Modifier -51 (multiple procedures): Use this code when multiple procedures other than E/M services are performed at the same session by the same provider. I usually see this modifier used with pain procedures since anesthesia services are only billed under the code with the highest base value even when the surgeon performs multiple procedures, DiDonato says.

Since the National Correct Coding Initiative (NCCI) was instituted, modifier -51 doesnt seem to be required as often for us to receive separate payments, says Karen Tabor, CCS-P, billing and accounts receivable coordinator at Kalamazoo Anesthesiology, PC, in Kalamazoo, Mich. We base our claims on the NCCI comprehensive codes instead of the individual components, and dont usually have any problems. The NCCI was implemented by Health Care Financing Association (HCFA) several years ago to standardize which multiple procedures should be reported under a master code rather than fragmenting different services and coding each part as if it were a separate service.

Modifier -59 (distinct procedural service): This modifier is commonly used in conjunction with the placement of an epidural catheter (62319, injection, including catheter placement, continuous infusion or intermittent bolus, not including neurolytic substances, with or without contrast [for either localization or epidurography], of diagnostic or therapeutic substance[s] [including anesthetic, antispasmodic, opioid, steroid, other solution], epidural or subarachnoid; lumbar, sacral [caudal]) for post-op pain relief. Including it on the claim identifies that the catheter was not used as the mode of anesthesia during the procedure.

Modifier -76 (repeat procedure by the same physician): Use this modifier if the physician needs to repeat a procedure. If the carrier considers members of the same group to be the same physician, some coders say this modifier also can arguably be used when an epidural catheter (62319) that was placed (by the attending physician during surgery) for post-op pain has failed and is later replaced by a member of the acute pain service.

Anesthesia Services Modifiers

Modifier -23 (unusual anesthesia): Barbara Johnson, CPC, MPC, of Loma Linda University Anesthesiology Medical Group in California says this modifier is primarily used for procedures that dont generally need anesthesia (such as when infants have a CT or MRI). Procedures such as an endoscopy or MRI might be performed under general anesthesia or MAC (monitored anesthesia care) if the patient is hypertensive or has some other serious underlying medical condition. Using anesthesia in these situations can lessen the risk of complications to the patient and allow the patient to be closely monitored. Many patients in these types of situations may not be able to have the procedure done without anesthesia.

Modifier -53 (discontinued procedure): This modifier is a big help to anesthesia, Johnson says. Many times we have cases that cancel after induction and before incision. This helps us bill for our physician time with the patient. DiDonato offers this example of a discontinued procedure: A patient has been prepped and induced by the anesthesiologist and is awaiting the arrival of the surgeon. Prior to incision, the patients vital signs indicate that it would not be advisable to proceed with the surgery so the surgery is canceled.

Note: Other modifiers that apply to this same scenario in an ambulatory services setting include -73 (discontinued outpatient procedure prior to anesthesia administration) and -74 (discontinued outpatient procedure after anesthesia administration), according to Tabor.

Modifier -58 (staged/related procedure or service by the same physician during the postoperative period): Sometimes a physician knows up front that a procedure will need a follow-up (staged) procedure during the post-op time, or that therapy will be needed after a surgical procedure. Use modifier -58 in these cases, such as when anesthesia is involved with a cystoscopy case and then later is involved with lithotripsy for the same patient. In this example, the lithotripsy would be coded with modifier -58.

Modifier -78 (return to the operating room for a related procedure during the postoperative period): Use modifier -78 when a follow-up procedure related to the original service is needed during the postoperative time and requires sending the patient back to surgery. It is used for cases such as a patient who has a post-op bleed and needs to return to the operating room for repair.

Modifier -79 (unrelated procedure or service by the same physician during the postoperative period): Patients with multiple medical problems sometimes require subsequent surgeries to address other medical conditions during the post-op period of an original surgery. Use modifier -79 in these cases, but remember that the ICD-9 codes for the procedures should be different.

Modifier -99 (multiple modifiers): Johnson, Tabor and DiDonato agree that this modifier is basically self-explanatory. If more than two modifiers are used for a particular procedure, modifier -99 needs to be added to the procedure code. How modifier -99 is reported in conjunction with the other modifiers will depend on the individual carrier. Check your local guidelines for coding requirements.