Modifier Coding Alert

Question: We had a young patient who came into the office for an ingrown toenail (11765). Initially the physician was prepared to have the anesthesiologist administer local anesthesia but within minutes the patient became extremely agitated in great pain and required general anesthesia. What modifier should I use: 23 or 47?

Rhode Island Subscriber

Answer: You don’t need a modifier for this situation. You would just report 11765 (Wedge excision of skin of nail fold [eg, for ingrown toenail]). The coder for the anesthesia provider will take care of the rest.

Modifier 47 (Anesthesia by surgeon) wouldn’t be correct because your physician didn’t administer the anesthesia and perform the procedure. When the physician performs both anesthesia and surgery, the anesthesia is included in the surgery.

Circumstances when modifier 47 (informational only) wouldn’t be used are:

• When an anesthesiologist administers the anesthesia
• For local anesthesia
• If the surgeon is monitoring the general anesthesia being performed by an anesthesiologist, Certified Registered Nurse Anesthetist (CRNA), resident, or intern
• When the surgeon administers the regional or general anesthesia, and the payer you are submitting to is Medicare because Medicare doesn’t cover this service
• With a surgical procedure code when the surgeon provides moderate sedation.

Modifier 23 (Unusual anesthesia) is also informational only and you should use it when anesthesiologists, CRNAs, or anesthesiologist assistants (AAs) perform general anesthesia on procedures that are normally performed under local anesthesia or with a regional block.

Even the anesthesia coder would not use modifier 23 with procedure codes that:

• Include the phrase “without anesthesia” in the descriptor.
• Normally are performed under general anesthesia.