Anesthesia Coding Alert

The answer might surprise you You know the routine: Your practitioner provides anesthesia for an out-of-the-norm case - during a child's MRI. You automatically append modifier -23 (Unusual anesthesia) to the procedure code and move on to the next claim. But before you go too far, take a closer look at the documentation - that's your tip-off to whether appending modifier -23 will actually trigger a denial, not a payment, for this service. Dig Into the Descriptor CPT's front-cover descriptor of modifier -23 seems basic enough by simply stating, "Unusual anesthesia." Its explanation in Appendix A, however, gives more details that you should consider:
 
"Occasionally, a procedure, which usually requires either no anesthesia or local anesthesia, because of unusual circumstances must be done under general anesthesia. This circumstance may be reported by adding the modifier -23 to the procedure code of the basic service."
 
Cases such as anesthesia during a child's MRI definitely meet the general criteria of "unusual circumstances." But because the more detailed explanation specifically refers to the use of general anesthesia, questions arise when the physician administers MAC (monitored anesthesia care) for the case. MAC usually involves sedation, but the patient does not lose consciousness and therefore does not require airway protection (intubation) as a patient under general anesthesia does. The question is whether you can append modifier -23 when the physician administers MAC instead of general anesthesia.
 
Tip: Begin your coding quest by verifying whether the case involved general anesthesia or MAC. If the physician administers general anesthesia, your part is easy - simply append modifier -23 as expected. But if the physician actually used MAC instead, it's time to decide on your next best option. MAC Option 1: Drop the Modifier Because CPT's descriptor does specify that modifier  -23 applies to cases with general anesthesia, some coders recommend that you don't append modifier -23 when the physician uses MAC.
 
"If the anesthesiologist says that it is a MAC case, I would probably submit the claim without a modifier," says Joanne Mehmert, CPC, Joanne Mehmert & Associates LLC, Kansas City, Mo. "If the claim is denied, I would appeal with a brief explanatory note pointing out to the carrier that the need is based on the child's age."
 
Emma LeGrand, CPC, CCS, with New Jersey Anesthesia Associates in Florham Park agrees, with one exception: "If the physician documents that he provided MAC but the patient reached the state of unconsciousness that is considered general anesthesia, I would attach modifier -23," she says. MAC Option 2: Use -23 With an Explanation Your second option is to append modifier -23 with an explanation that the physician used MAC because of the patient's age (the explanation goes in Box 19 of a paper [...]