Primary Care Coding Alert

Question: We had a young patient who came into our office for an ingrown toenail (11750). 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 IslandSubscriber

Answer: You don’t need a modifier for this situation, since an anesthesiologist provided the anesthesia. You would just report the code for the procedure that your physician performed, such as 11750 (Excision of nail and nail matrix, partial or complete [e.g., ingrown or deformed nail], for permanent removal). The coder for the anesthesia provider will take care of the rest.

Modifier 47 (Anesthesia by surgeon) wouldn’t be correct, because your FP didn’t administer the general anesthesia and perform the procedure. When your FP performs both regional or general anesthesia and the associated surgical procedure, the anesthesia is included in the surgery, and modifier 47 is appended to the surgical procedure code to indicate this circumstance. Provision of local anesthesia and the procedure does not require a modifier.

Thus, circumstances when modifier 47 (informational only) wouldn’t be used are:

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

You should use Modifier 23 (Unusual anesthesia) when a procedure that normally requires no anesthesia or local anesthesia must be done under general anesthesia because of unusual circumstances. In such circumstances, modifier 23 is appended to the surgical procedure code.

However, in your situation, it probably would still not be appropriate to use modifier 23, since the anesthesia was provided by an anesthesiology professional, and 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.