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What is the correct code for surgical procedure with general anesthesia?

This is an article for medical coding students who want to learn more about surgical procedure codes, particularly the use of modifiers for general anesthesia. We are going to tell you some stories about modifiers. Each story is meant to provide an overview of how modifiers are used in the field. These stories are meant to serve as illustrative examples. To find out more, you should check with the latest AMA CPT coding guide and be sure to always be in compliance with the law and to keep UP with changes!.

About Medical Coding

Medical coding is an essential component of healthcare, and it's critical that you use correct codes. These codes allow insurance companies to know what procedures and treatments were administered to a patient. They're critical for billing purposes, allowing providers to receive payment for services rendered. We use coding in all areas of medical specialization.

CPT Codes - Using Them Correctly

CPT stands for Current Procedural Terminology. These codes are proprietary to the American Medical Association (AMA), which is the governing body responsible for creating, maintaining, and publishing them. In order to use these codes, a healthcare professional or organization is legally required to purchase a license from AMA. Failing to obtain a license or use the latest version is a violation of US regulation and is punishable by law.

CPT Modifier 22 - Increased Procedural Services

We are going to start with a common modifier for surgical procedure. Modifier 22, "Increased Procedural Services", applies when there are significantly more services or resources than usual used for a procedure.

Story 1: Open Treatment of Radiocarpal or Intercarpal Dislocation

Let's say a patient has a complex fracture of the radius and carpal bones of the wrist requiring a difficult open surgical procedure. Imagine that the fracture extends across the wrist joint. Due to the severity, the patient's wrist required an extended surgical approach, which demanded additional surgical time and more resources, compared to a simple radiocarpal dislocation.

The patient had a significant car accident with a high-energy impact injury to the wrist. The patient complained of excruciating pain. A series of X-rays showed that the patient had a radiocarpal joint dislocation involving three carpal bones. The patient required immediate medical attention due to the potential damage to blood vessels and nerves that supply the hand.

The provider decided to GO to the OR and treat the wrist through open reduction and fixation of multiple fractures. He also had to reduce multiple dislocated carpal bones.

As you can see, this case presents a high level of difficulty and requires more work for the provider. The provider may also need to order more advanced imaging during the procedure to visualize the fracture. This situation might also demand longer postoperative care with multiple physical therapy sessions. We can say that this case required "increased procedural services" since it went beyond the usual amount of work for a typical carpal dislocation. That is why, as a coder, you will append CPT modifier 22. Modifier 22 is an important tool for accurate coding!.

Code Examples

So how would we use modifier 22 for our case? Let's assume that the physician chose to report procedure code 25670 for open treatment of the carpal dislocation.

You would report code 25670 with modifier 22 attached to it: 25670-22.

CPT Modifier 47 - Anesthesia by Surgeon

Another essential modifier to learn is modifier 47. We need it when a surgeon administers anesthesia for a surgical procedure. Modifier 47 lets US distinguish this type of service from services where a separate anesthesiologist administers the anesthesia. This distinction matters when we are billing for the procedure.

Story 2: Orthopedic Surgery with Anesthesia

In this case, we are dealing with a knee arthroplasty. This is the replacement of a patient's knee joint. This complex surgery involves replacing damaged or worn knee cartilage with prosthetic components.

The patient was a retired nurse, 67 years old, with severe osteoarthritis in her right knee, which was severely limiting her daily activities and making even the simple task of walking painful.

After consultation, she agreed to knee replacement surgery. The doctor told her HE would personally administer the anesthesia since HE was comfortable doing it. This was agreed upon with the patient beforehand.

This case demonstrates the application of modifier 47! Since the physician performed the knee replacement and the anesthesia, you will attach modifier 47 to the surgery code. This clearly indicates that the doctor who did the surgery, also administered the anesthesia.

Code Examples

Assume that the doctor performed code 27447, total knee arthroplasty, along with administering the anesthesia. We would report this as follows: 27447-47.

CPT Modifier 50 - Bilateral Procedure

Modifier 50, "Bilateral Procedure", is used when we need to report a procedure done on both sides of the body at the same time. It's often used in surgeries that treat paired body parts like wrists, ankles, knees, or eyes.

Story 3: Wrist Dislocation Surgery

Our patient is a young athlete, 20 years old. He recently fell and sustained bilateral wrist dislocations - both wrists at the same time, during a game! The young man presented to the ER. The emergency physician noticed an obvious deformity of both wrists after a fall, and HE diagnosed the injuries as bilateral carpal dislocations of both the left and right sides of his wrists. The emergency physician was also able to diagnose the extent of injuries with simple imaging. X-ray showed that HE has both right and left wrist carpal dislocations.

This type of trauma can have serious implications, such as damage to nerves or blood vessels supplying the hands.

After examining him, the doctor explained that HE would perform an open procedure to stabilize the dislocated bones in both wrists during the same surgical session. The surgeon will be performing two procedures on the same day - a simultaneous operation on the left and the right sides.

In this example, the doctor has decided to treat the two dislocations during the same procedure. Since the right and left wrists are considered bilateral, you will attach modifier 50 to the code representing the surgery. You need to make sure you are reporting the code for the open procedure and appending modifier 50 for the fact that the operation was performed bilaterally!

Code Examples

To illustrate this situation, assume that the physician reported code 25670, for the open procedure.

Because this procedure was done on both sides (bilaterally), we would report this as 25670-50.

Other Common Modifiers in Medical Coding

Let's explore some other commonly used CPT modifiers, their purpose, and a story related to each of them. These examples will illustrate different ways CPT modifiers are applied in medical billing and coding, even for surgical procedures involving general anesthesia. Keep in mind these examples only focus on how CPT modifiers are used in practice. It is important to stay current on changes and always consult the latest AMA CPT codes.

CPT Modifier 51 - Multiple Procedures

Modifier 51 "Multiple Procedures", is used to report the second or subsequent procedure that's performed during the same surgical session, on the same day.

Story 4: Fracture Treatment During The Same Surgical Session

Let's imagine our patient has a fracture of both his radius and ulna. During surgery, the doctor notices that there are more than one fracture - multiple fractures! - in both the radius and the ulna. The surgeon has already treated one fracture. The surgeon decides to treat the additional fractures that HE encounters during the same surgical procedure, instead of waiting for a different surgery.

Since HE is performing multiple procedures - treating more than one fracture - during the same session, you would append modifier 51 to each of the procedures HE is performing after the first one. The surgeon could report two fracture treatment codes in this situation.

Code Examples

In our example, assuming the surgeon is performing two fractures treatment procedures during the same session, HE would report the second one using modifier 51.

He would report the second fracture procedure as 25560-51 for instance.

CPT Modifier 52 - Reduced Services

Modifier 52 "Reduced Services", is used when a physician only performs a portion of the full procedure.

Story 5: Partial Treatment

We're dealing with a patient, who, due to specific factors, like existing health issues or complications during surgery, can't undergo the full intended surgery.

Imagine that the patient needs a fracture treatment. But HE has a history of hypertension which has a great risk of surgery and can affect the type of surgery needed. The physician planned for open reduction of the fractured tibia and ankle, which might have caused a greater risk for the patient. After talking with the patient, HE explained the procedure and the risk of possible complication and suggested doing a closed reduction instead, due to the risks that come with the open approach.

The physician ended UP performing a closed reduction with casting of the fractured tibia. The patient was satisfied with the choice and agreed to it. Although the initial treatment plan included an open approach, the physician ended UP only performing the first stage. The surgeon performs only the partial procedure - closed reduction with casting.

Since we've seen a partial procedure, the surgeon should report the reduced services using modifier 52!.

Code Examples

For the closed reduction and casting code 27775, we will add modifier 52 to show that the surgeon did not perform the complete intended procedure. In this case, the final reported code is: 27775-52.

CPT Modifier 53 - Discontinued Procedure

Modifier 53 "Discontinued Procedure", is used when a surgical procedure is abandoned during the surgery session for certain reasons.

Story 6: Discontinued Surgery During Session

Imagine a patient, an elderly patient with health issues like heart problems, comes in for knee surgery.

This time, we're talking about a complex surgery, a total knee arthroplasty. A nurse accompanies the patient to the surgery room for the knee replacement surgery. It looks like everything is fine initially.

But then the patient’s blood pressure begins to rise suddenly and drastically. This puts the patient at serious risk. Due to concerns about his heart, the surgeon has to make a quick decision to stop the surgery to stabilize the patient's condition, which had deteriorated during the procedure.

Since the surgery was not finished, you'd attach modifier 53 to the knee replacement code to show that the surgery was interrupted before the original plan could be finished. You may also need to use a code for the monitoring and treatment provided after the surgery was stopped!

Code Examples

Using our total knee replacement example, assume that the doctor planned to report code 27447. Since the surgery was discontinued before completion, you would report code 27447-53.

CPT Modifier 54 - Surgical Care Only

Modifier 54 "Surgical Care Only", is used when the physician only provides surgical care and is not going to provide any follow-up care after the surgery. The provider might choose not to provide post-surgical care, but they may still provide post-surgical orders for the patient.

Story 7: Fracture Management Case

Picture this: We have a patient who suffered an elbow fracture that required surgery. The provider who performed the open reduction and fixation (ORIF) has chosen to handle the initial management of the fracture.

But it turns out, there is a different specialist who will be overseeing the follow-up care after the surgery, including physiotherapy and monitoring the recovery process.

In this scenario, modifier 54 is appended to the fracture surgery code to specify that only the surgical care was provided and the physician did not take charge of post-operative follow UP care! You would also need to include in the notes that a specialist is in charge of post-op care.

Code Examples

Assume the fracture treatment code is 24650. For our case, the final reporting would look like this: 24650-54.

CPT Modifier 55 - Postoperative Management Only

Modifier 55 "Postoperative Management Only", is used when a physician only manages the post-surgical follow-up, not providing surgical care.

Story 8: Joint Replacement Case

A patient needs knee replacement surgery for advanced arthritis. The primary provider for the patient performs the total knee replacement. This provider may decide to transfer the care to a specialist for all subsequent care after the surgery.

Another physician will be overseeing post-operative follow-up visits to manage recovery, ensure appropriate healing, and handle any potential complications, as well as provide physiotherapy prescriptions to aid in rehabilitation.

In this case, because only the follow-up is performed, you would need to append modifier 55 to the post-operative follow-up code for knee replacement, and it is not used to report the knee replacement code.

Code Examples

For instance, if the provider is reporting a 99213 code for post-operative knee management, the final reporting would be: 99213-55.

CPT Modifier 56 - Preoperative Management Only

Modifier 56 "Preoperative Management Only", is used to indicate a provider's role in pre-operative care but not surgical care.

Story 9: Preparing for a Major Procedure

Imagine you are preparing a patient for surgery for a hip fracture. This involves medical history and a physical examination, which may include ordering x-rays or imaging to visualize the fracture.

The surgeon explains to the patient the surgical process. They also talk about risks, complications, and what to expect after surgery, including physical therapy and other things needed for proper healing.

You will need to apply Modifier 56 to a visit code like a 99213 if the physician only did the pre-operative care.

Code Examples

If we were to report the code for the initial pre-op visit, we would attach the modifier to it like this: 99213-56.

CPT Modifier 58 - Staged or Related Procedure

Modifier 58 "Staged or Related Procedure", is used when a staged procedure is performed as part of a larger surgical procedure. Staged procedures are those that are planned and completed in several steps during a course of treatment. A doctor will do a staged procedure on the same patient if the full procedure can't be done all at once due to the patient’s condition. The procedure may also be too extensive, complex, or the surgeon doesn't have the resources for the whole procedure at one time.

Story 10: Staged Procedures

Let's say the patient has a massive open fracture of the tibia. This kind of fracture needs careful and staged surgical repair. You have a very serious case here.

The first part of the staged procedure involves stabilizing the fracture, the initial treatment which can take UP to two surgeries depending on how complex the fracture is, depending on how badly the fracture was damaged. The provider performs the surgery, stabilizing the fracture so that the patient can bear weight on the leg again.

A later surgery will address the complex fracture with bone grafts and may involve skin grafting or further repair depending on how bad the patient's fracture is, once the initial surgical stabilization has had time to heal.

Modifier 58 will need to be added to each code that is used to represent the surgical procedures to show that they are related to the initial surgery that was completed. This modifier shows that this surgery is one of several steps for the procedure.

Code Examples

Assuming the physician uses code 27778 for the initial stabilization, the second procedure, let’s assume the doctor chose 27775 for the closed reduction and casting, will then be reported as 27775-58.

CPT Modifier 59 - Distinct Procedural Service

Modifier 59 "Distinct Procedural Service", is used to clarify that two procedures are distinct from each other and would not have been done together if not for a particular condition.

Story 11: Treating Unexpected Conditions

Imagine a patient has a tumor that needs to be removed. But during surgery, the surgeon notices another problem, which HE decides to deal with during the same session to avoid an additional surgery.

He will be doing a separate and distinct procedure to take care of this issue during the same surgery session to address this situation.

When this occurs, the surgeon needs to document the details carefully, explaining the reason for the additional procedure, why it was done during the same surgical session, and the details of the distinct procedures.

You would need to attach Modifier 59 to each of the codes used to describe the distinct procedure because it is an additional and separate service that wasn’t planned and not part of the initial plan.

Code Examples

For example, assume the tumor removal procedure code is 21900 and the distinct procedure code for the unplanned situation is 21625. Then the final coding will include 21900-59 and 21625.

CPT Modifier 62 - Two Surgeons

Modifier 62 "Two Surgeons", is used to report services performed by two surgeons, when each surgeon independently provides the same service during the procedure. The services could be for the same anatomical region.

Story 12: Working Together for One Procedure

Picture a scenario where a patient needs a very complicated surgical repair. For a successful result, it involves more than one surgeon for different reasons - perhaps one surgeon is specializing in a specific type of procedure. Maybe two surgeons are involved for different aspects of a very complicated surgery that requires expert help from different surgeons.

When you encounter this situation, you should use modifier 62 with a surgical procedure code.

Code Examples

For example, if the primary procedure is an open procedure, for instance, code 25670, for a carpal dislocation that involves two surgeons, you will report 25670-62.

CPT Modifier 73 - Discontinued Outpatient Procedure

Modifier 73 "Discontinued Outpatient Procedure", is used when a procedure performed in an outpatient setting (like a surgery center) is stopped before anesthesia was administered.

Story 13: Changing Plans

A patient goes to an outpatient surgery center for a knee arthroscopy, but while waiting in the pre-operative area, the doctor learns the patient’s insurance might not cover the procedure, based on certain limitations. After assessing the case, the provider feels it's not appropriate to proceed with surgery under those circumstances. This might be due to the cost being high and unexpected or the patient might also not want to risk financial harm due to an insurance denial.

When the doctor has to change plans and stop the procedure before anesthesia is given, you would append Modifier 73 to the arthroscopy code to clearly reflect the situation! This helps make sure the insurance company knows why the procedure was not finished.

Code Examples

Assuming the arthroscopy code is 29880, the code with the modifier will be reported as 29880-73.

CPT Modifier 74 - Discontinued Outpatient Procedure (after anesthesia)

Modifier 74 "Discontinued Outpatient Procedure", is used when a procedure is stopped during the session and after anesthesia was already given in the outpatient setting (surgery center or hospital outpatient department).

Story 14: Anesthesia, Then a Halt

Imagine a patient, an older patient with a history of heart problems, who is in for surgery, for a carpal tunnel release.

This patient has had many health problems. He was prepped and ready to receive the anesthesia and undergo the surgery in the ambulatory surgery center. But during the process, HE begins having some discomfort and develops chest pains. His blood pressure and heart rate are high.

Due to his previous conditions and the high risk HE presents during surgery, the surgeon makes a critical decision to postpone the surgery.

In this situation, the procedure was started in the outpatient facility, anesthesia was administered, and only afterward was the procedure halted. You would append modifier 74 to the carpal tunnel release code. This helps clarify that anesthesia was already administered in the outpatient setting, but the procedure was still stopped!

Code Examples

Let’s say that the provider was going to perform carpal tunnel release using code 64721. The correct coding to represent that the surgery was halted would be 64721-74.

CPT Modifier 76 - Repeat Procedure or Service

Modifier 76 "Repeat Procedure or Service", is used when a physician performs the same procedure again for the same patient, under their care, as long as it is being done for the same condition.

Story 15: Second Attempt

The patient has an elbow fracture that requires a closed reduction - that's realigning the bone by hand without surgery. During the attempt to set the bone back into place, the provider realizes that it didn't completely reduce. This means that the elbow fracture did not align well even with a lot of manual manipulation. The fracture did not reduce, and therefore needs another attempt.

Since the closed reduction was done during a previous visit, and the physician is now performing it again because the bone wasn't successfully realigned the first time, modifier 76 is added. You will be adding modifier 76 to the fracture treatment code 24650 for instance.

Code Examples

The report will be 24650-76.

CPT Modifier 77 - Repeat Procedure or Service By Another Physician

Modifier 77 "Repeat Procedure or Service By Another Physician", is used when a physician performs the same procedure for the same patient as before, but the procedure was previously done by a different doctor.

Story 16: Transfer of Care

Let's imagine a patient went to the ER because of an ankle fracture, but the ER provider did not feel qualified to perform the complex procedure for fixing the ankle fracture. Therefore, they referred him to an orthopedic surgeon. The patient was discharged from the emergency department, and later HE went to see a specialist.

Now the orthopedic surgeon is treating the same patient and performing a procedure that the previous provider, in this case, the emergency provider, already tried but did not feel qualified for. If the previous provider had started the procedure but stopped without completing it and a different provider is continuing it then you would not need a 77 modifier because 53 or 74 is used.

This modifier is essential when another provider repeats a procedure performed before by a different provider! Modifier 77 is reported on the procedure code performed by the second physician. If a previous physician or provider performed an initial attempt, then a repeat procedure is performed by another physician. Modifier 77 is added to the new provider’s code. In this case, 77 is used to indicate that the same procedure was performed on the patient before. But the prior procedure was completed by another doctor.

When there is a need for a repeat procedure due to a failure of the original procedure or there is a need for revision or another procedure is required to correct or improve an already completed procedure done by a previous doctor. For example, 77 may be appropriate in the case of a follow-up procedure that corrects a failed or unsuccessful procedure that was originally done by another provider. You should keep in mind that it is also dependent on the provider's preference. Some providers might have an established process for sharing services and using modifier 59 when a new provider is taking care of the patient for additional and related procedures and that they want to use Modifier 77 only for certain cases. For instance, in a practice setting with multiple providers in the same specialty, the provider may report the procedure and append 59 to it if the service is distinct but provided during the same encounter for the same patient. They might report the code and append 77 if another physician sees the same patient after an encounter with another physician in the practice.

Code Examples

Assuming the surgeon is using code 27775 to treat the fracture in this case, then you would report 27775-77.

CPT Modifier 78 - Unplanned Return To The Operating Room

Modifier 78 "Unplanned Return To The Operating Room", is used to describe a situation where the physician returns to the OR after the original surgical procedure, during the same surgical session, to perform an additional, but related, procedure that was not initially planned.

Story 17: More Than One Operation in The Same Visit

Imagine a patient undergoing a surgery for a fracture in his lower leg. It's a serious injury that needs surgery for stabilization. In this case, the provider used a combination of different methods and tools to put the fracture together during the procedure, using pins, plates, and screws. He closes the incision, and after checking the X-ray to confirm proper alignment and stability of the leg, sends the patient to recover in the post-operative area.

However, later, while examining the X-ray, the provider notices that the fracture isn't perfectly aligned, or there may have been issues with the placement of some of the metal implants. In order to take care of these issues, the patient needs another procedure! The doctor decides that it's necessary to perform an additional procedure. Since HE didn’t realize HE needed a second procedure in the OR until HE reviewed the x-ray later, HE must attach Modifier 78. In this case, Modifier 78 shows that the procedure is being performed to fix or refine an issue with the initial surgery done on the same day!

Code Examples

Let's say that the physician originally used code 27776 for the lower leg procedure. The provider then decides that HE needs to re-operate and perform a procedure. Since this is being performed for an additional, but related procedure, because the doctor already started the surgical procedure, and returned to finish the job on the same day, you would report code 27776-78, as the repeat procedure, because the initial procedure, in this case, code 27776, was already reported previously on the same day.

CPT Modifier 79 - Unrelated Procedure Or Service By The Same Physician

Modifier 79 "Unrelated Procedure Or Service By The Same Physician", is used when a provider performs a procedure that is not related to the primary surgery that was already done for the patient. If the surgeon has already treated the patient with an original procedure, and the surgery isn’t directly connected to it, you would attach this modifier to the code that represents the new procedure. This modifier signifies that the surgeon has performed another procedure or service during the same session or visit. These procedures are not associated with the primary procedure for which the patient initially sought treatment. The key thing here is that the service or procedure should be an entirely unrelated, independent surgical intervention for a different diagnosis or condition from the patient’s primary reason for the surgery.

Story 18: Surgery in the Same Visit

A patient arrives in an outpatient surgery center to receive an incision and drainage for an abscess on their hand. However, upon examining the patient, the doctor realizes the patient also has a dislocated elbow.

The surgeon decides that it would be more efficient and safer for the patient to perform an additional procedure. The surgeon needs to manage both of the conditions: He decides to treat both, doing an open reduction for the dislocated elbow.

Since the elbow is not related to the abscess, but is also a problem the surgeon will be fixing during the same surgical visit. In order to demonstrate that it's separate, we need Modifier 79! It shows the distinct procedure performed during the same visit as the abscess. This tells insurance companies that this procedure is distinct, independent, and unrelated to the first surgery.

Code Examples

For example, the original procedure for the abscess, using code 27810, would be reported as 27810, while the dislocated elbow procedure 24650 would be reported as 24650-79 because the procedure is independent and separate from the first one.

CPT Modifier 80 - Assistant Surgeon

Modifier 80 "Assistant Surgeon", is used to report the services performed by an assistant surgeon during a surgical procedure. When an additional surgeon helps during surgery, this modifier must be appended to the assistant surgeon’s code. An assistant surgeon’s role is to provide assistance, working with the primary surgeon.

Story 19: Getting An Extra Hand

Imagine that we have a complex knee surgery - this is a total knee replacement.

It’s common to have a surgeon’s assistant help during major surgeries to ensure things GO smoothly, reduce the workload for the surgeon, and for improved care. For instance, an assistant surgeon might hold tissue and assist with suturing, as well as managing blood loss.

Since there's an assistant surgeon involved, they would be reporting the procedure code as well. But they would need to add Modifier 80.

Code Examples

If the assistant surgeon is reporting the total knee replacement surgery (code 27447), then they will use code 27447-80.

CPT Modifier 81 - Minimum Assistant Surgeon

Modifier 81 "Minimum Assistant Surgeon", is used when an assistant surgeon assists with a surgery in the minimal assistant role.

Story 20: Minimal Assistance

We have a case with an open procedure to treat a complex fracture in the forearm. This procedure typically takes a lot of time and effort. The provider might decide that an assistant surgeon might be helpful in holding retractors to facilitate access and view during the surgery, but they do not have a lot of work to do. The surgeon may want the additional support in the operating room but this support isn't required, it's just optional, because they have experience doing this procedure.

In cases where there is minimal assistance by an assistant surgeon, this modifier will be needed for the code they are reporting. For instance, they may assist with instrument and supply management.

Code Examples

Let's say the code is 24640. The assistant surgeon would report code 24640-81.

CPT Modifier 82 - Assistant Surgeon When Qualified Resident Surgeon Is Not Available

Modifier 82 "Assistant Surgeon When Qualified Resident Surgeon Is Not Available", is used to report services by an assistant surgeon, when the qualified resident surgeon in the same training program isn't available to perform assistant surgery tasks.

Story 21: Assistance from Another Specialist

We have a scenario where there is a need for an assistant surgeon for a complicated laparoscopic procedure. Imagine that a qualified resident is normally

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CPT Modifiers for Surgical Procedures with General Anesthesia: A Guide for Medical Coders