Modifier Coding Alert

Published on Fri Feb 20, 2015 PDF

Question: Our surgeon performed an endometrial biopsy (58558). Prior to surgery, she initiated a regional block (64421) because the patient was becoming agitated and the anesthesiologist hadn’t entered the room. Is there a modifier I should use and on which service?

Wyoming Subscriber

Answer: Consider modifier 47 (Anesthesia by surgeon) with 58558 (Hysteroscopy, surgical; with sampling [biopsy] of endometrium and/or polypectomy, with or without D & C) because your surgeon initiated the anesthesia in the absence of an anesthesiologist. Then, report 64421 (Injection, anesthetic agent; intercostal nerves, multiple, regional block) for the block as indicated.

Warning: Payers may not recognize modifier 47 because surgeons rarely administer the anesthesia for a procedure that they are performing. Using modifier 47 indicates an atypical situation occurring when an anesthesiologist is not present.

Note: Do not use modifier 47 for the administration of a local anesthetic by your surgeon. Global periods include local anesthesia for surgery so there is no need to bill local anesthesia separately.

“I don’t think this modifier is used much since Medicare, and I think most other payers, don’t pay extra for the surgeon doing the anesthesia,” states Laureen Jandroep, CPC, CPC-H, CPC-I, CPPM, CMSCS, CHCI, founder and CEO at CodingCertification.org in Oceanville, N.J. “So most surgeons will not take on that extra risk and will have an anesthesiologist brought in to the room.”

CMS rule: Although the modifier 47 definition in Appendix A of the CPT® manual specifically states that “Regional or general anesthesia provided by the surgeon may be reported by adding modifier 47 to the basic service,” CMS does not cover such a service with modifier 47 when the provider is a surgeon. They will cover when you use 47 to report anesthesia the attending or assistant surgeon provides.