CHAPTER 9 and CHAPTER 11 – Modifiers and Anesthesia
Pg 346
Anesthesia – induction or administration of a drug to obtain partial or complete loss of sensation
 procedure codes are divided by anatomic site and then by specific type of procedure
 The last 4 subsections in Anesthesia are not organized by site / procedure
Analgesia
– absence of pain
The More Common Types of Anesthesia: (pg 346-348) a. Endotracheal
– insertion of a tube into the mouth or nose and passing the tube into the trachea for ventilation. b. Epidural – injection of an anesthetic agent into the epidural spaces between the vertebrae aka (also known as) peridural, epidural, or epidural block. c. Spinal
– injected into the subarachnoid space around the spinal cord. d. General – state of unconsciousness a. inhalated b. intramuscularly c. rectally d. intravenous e. Regional
– used to interrupt the sensory nerve conductivity in a rregion of the body - (aka) forming a wall of anesthesia around the site by means of local injections a. Nerve block -aka i. Block ii. Block Anesthesia f. iii. Conduction Anesthesia b. Blood Patch
– A procedure in which a cF leak is closed by means of an injection of the patient’s blood into the area that was used during spinal anesthesia
Local
– Anesthesia is applied as a topical or through use of an injection i. Patient-controlled analgesia – a system that allows the patient to administer a drug such as morphine g. PCA (patient controlled analgesia)
– allows the patient to administer an analgesic drug such as morphine to control pain. h. MAC (monitored anesthesia care) – provided by an anesthesiologist or i. j.
CRNA.
Regiona l
– uses an injection to target the nerves of the area being treated.
Spinal and epidural – anesthesia administered into the CSF (cerebral spinal fluid or epidural area of the spine. Spinals are usually for procedures administered below the waist.
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CHAPTER 9 and CHAPTER 11
– Modifiers and Anesthesia
for Anesthesia Payment
– pg 351 - 360
1. B = Base Unit
Anesthesia services are compared to each other and then numerical values were assigned.
2. T = Time – pg 354 a. Anesthesia services are provided based on the time during which the anesthesia was administered, in total minutes. i.
.
3. M = Modifying Unit
– 2 factors a. Qualifying Circumstances – there are times when circumstances make administering the anesthesia more difficult. i. Codes begin with 99. They are both in the Anesthesia section and the
Medicine section. Both use the + symbol indicating they are only add-on codes. ii. Find in the CPT Index under “Anesthesia, Special Circumstances”
– indicates patient’s condition at the time of b. administration being given. Located on the inside cover of the CPT book . And on pgs 358-359 i. P1 = A normal healthy patient ii. P2 – A patient with a mild systemic disease iii. P3
– A patient with severe systemic disease iv. P4 – A patient with severe systemic disease that is constant threat to life v. P5 – A moribund patient who is not expected to survive without the operation vi. P6 – A declared brain-dead patient whose organs are being removed for donor purposes
Conversion Factors
– dollar value of each unit. Vary with geographic location because the practice of medicine varies from one region to another
Concurrent Care Modifiers
– ex. CRNA’s who administer the anesthesia under the supervision of a physician. Pg 360-361.
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CHAPTER 9 and CHAPTER 11 – Modifiers and Anesthesia
CPT Two-Digit Modifier

These are placed at the end of the code to indicate that something unusual occurred.
 They are located on the inside cover of the CPT book.
 They are explained on page xv of the CPT book.

They are also located in Appendix A of the CPT book.
 Also located in the back of the HCPCS book
 Website – http://www.wpsmedicare.com/part_b/education/modifiers.shtml
Used to indicate the following types of information:
1.
Altered service a. Prolong service b. Service greater than is usually required c. Unusual circumstances d. Part of a service
2.
Bilateral procedure
3.
Multiple procedures
4.
Professional part of the service/procedure only
5.
More than one physician/surgeon
(-22) – Increased procedural services – service provided was greater than normal. A special report would accompany the billing. procedures only (pg 251-252)
(-23) – Unusual Anesthesia - the service provided by an anesthesiologist to indicate a service for which general anesthesia was used when normally the anesthesia would have been local or regional, because of the circumstances, the patient had to be put under. (pg
252-253)
(-24)
– Unrelated E/M service by the same physician during the post op period – patient comes in for an office visit which is unrelated to the reason the patient had a minor or major surgery provided. Evaluation and Management visit codes only. (pg 253)
(-25)
–
Significant separately identifiable E/M service by the same physician on the day of a procedure or other service – ex. Pt has an injection or lesion removal or something minor done. This modifier tells the insurance company that something other than an office visit took place. (Post op days / global period for a MINOR procedure is 0-10 days). Evaluation and
Management visit codes only. (pg 254)
(-26)
– Professional component – ex. Radiology services. You have the (TC – technical component or the actual performance of a test done) and then the professional component
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(reading of the report). Used on the 70,000 codes and on some of the 90,000 codes. (pg
254-255)
CHAPTER 9 and CHAPTER 11 – Modifiers and Anesthesia
(-32)
– Mandated services - This tells the insurance company that somebody told the patient to go see the doctor. Mostly used by workman’s compensation and other companies when hiring employees, will request a pre-exam be performed. Evaluation and Management visit codes. (pg 256)
(-47) – Anesthesia by surgeon – Tells the insurance company that the anesthesia was given to the patient by the doctor, NOT the anesthesiologist. (pg 256)
(-50) – Bilateral procedure – (50 = RT and LT) - procedure is done on both sides of the body.
Used on the procedure code only. Procedure code only. (pg 256-257)
(-51)
– Multiple procedures – tells the insurance company that more than one procedure was done. Use this modifier on the 2 nd , 3 rd , 4 th procedures, but this modifier does not go on the first procedure done. Procedure code only. (pg 257-261)

3 times it is used: o Same Operation, Different Site o Multiple Operation(s), Same Operative Session o Procedure Performed Multiple Times
(-52) – Reduced services – indicates procedure was done but only a part of the procedure or service was done or had to be stopped. Procedure code only. (pg 261-262)
(-53) – Discontinued procedure – the procedure was stopped because of the patient’s condition or something happened during the procedure. Procedure code only. (pg 264)
(-54) – Surgical care only (known as co-management) – used when a transfer of care takes place. Ex. Patient has a procedure and the post op care is to be provided by someone else.
Payment is 80% of the total surgery
– Procedure code only. One practice that utilizes this modifier is Ophthalmology. (pg 264)
(-55)
– Post operative management only – someone else did the surgery and now this physician is going to do the post op care. Payment is 20% of the total surgery. Procedure code only. One practice that utilizes this modifier is Ophthalmology, (pg 265)
(-56)
– Preoperative management only –Evaluation and Management service indicating a doctor did a physical before the patient has surgery. (pg 265-266)
(-57)
– Decision for surgery – Evaluation and Management visit codes only when the patient is going to have a major surgery. A major surgery is one that has a global period / post op days = to 90 days. (pg 266)
(-58)
– Staged or Related procedure or service by the same physician during the post op period. Procedure code only. (267)
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(-59) – Distinct Procedural service – when one service is included in another service. Use this when you want to tell the insurance company that the services are two distinct services.
Procedure codes only. (pg 268)
CHAPTER 9 and CHAPTER 11 – Modifiers and Anesthesia
(-62) – Two surgeons – when a procedure is done by two physicians of two different specialties, but each physician did two different things. (pg 269-270)
(-63)
– Procedures performed on infants less than 4 kg / 8.8 lb. (pg 270)
(-66) – Surgical team – used on very complex procedures that require several physicians, usually of different specialties, to complete the procedure. Procedure code only. (pg 270-
271)
(-76)
– Repeat procedure or service by the same physician. Procedures or tests only. (pg
271)
(-77) – Repeat procedure by another physician. Procedure or test only. (pg 271)
(-78) – Unplanned return to the operating/procedure room during the post op period.
Procedure only. (pg 278)
(-79) – Unrelated procedure or service by the same physician during the postoperative period. Patient has surgery for something else in the post op period that has nothing to do with the surgery that was done previously. Procedure only. (pg 273)
(-80) – Assistant surgeon – a surgical assistant is one who provides service to the primary surgeon during a surgical procedure. Procedure only. (pg 274)
(-81) – Minimum Assistant Surgeon – physician’s assistant is available for part of the surgery but not the whole surgery. Procedure only. (273-274)
(-82) – Assistant surgeon (when qualified resident surgeon not available). Procedure only.
(274)
(-90)
– Outside lab is used. Laboratory test only. CPT codes 80,000 section. (pg 275)
(-91) – Repeat clinical diagnostic lab test. Laboratory test only. CPT codes 80,000 section.
(pg 276)
(-92) – Alternative lab platform testing – those incidents when a kit or transportable instrument is used in a lab test. Laboratory test only. CPT codes 80,000 section. (pg 276)
(-99) – Multiple modifiers – used when 3 rd party payers won’t take the addition of multiple modifiers to a code. Evaluation and Management codes and Procedure codes. (pg 276)
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