Medical billing often feels like learning a new language, especially when you encounter specific coding scenarios that fall outside the daily routine. One such scenario involves a surgeon taking on the dual role of both a primary surgeon and an anesthetist. Medical billers file claims for such circumstances by using modifier 47.
In this guide, we will explain how you can use this modifier in your claims without triggering denials. So, let’s start.
Modifier 47 – Description
Modifier 47 is simply defined as:
“Anesthesia by Surgeon/Assistant Surgeon”
In most surgeries, the surgeon’s role is to perform the surgery, while a separate specialist, an anesthesiologist, manages the patient’s sedation and pain control. However, this is not always the case. Sometimes, the surgeon/assistant surgeon has to manage and administer anesthesia as well. In such a scenario, modifier 47 is used to indicate the surgeon’s additional service.
The modifier’s primary purpose is to alert the payer that the physician who performed the surgical intervention also administered either regional or general anesthesia. However, an important point to note here is that you can use the 47 modifier only for regional or general anesthesia, not for local anesthesia.
Another essential thing to keep in mind is that, unlike other anesthesia-related modifiers, 47 is appended directly to the surgical CPT code, not the anesthesia code. Attaching it to an anesthesia code is a common billing error that results in immediate rejection.
It is also vital to note that for many payers, particularly Medicare, this is an informational-only modifier. This means that while it describes what happened during the surgery, it does not result in an additional payment.
Scenarios Where a Modifier 47 is Applicable
To clear out any confusion, let’s look at a couple of scenarios in which the modifier 47 can be used:
Scenario 1
Imagine an orthopedic surgeon is performing a complex knee procedure. Due to specific clinical needs or resource limitations, the surgeon personally administers a femoral nerve block to anesthetize the leg before making the incision. The surgeon then completes the knee surgery.
In this case, the claim would list the knee surgery CPT code (27447) along with modifier 47 to report the surgeon’s additional services.
Scenario 2
Suppose a patient is brought to the operating room for an emergency spine surgery. However, since it is a rural ambulatory surgical center and the only anesthesiologist on duty is busy, the physician decides to manage and administer general anesthesia himself. After sedation, the physician completes the surgery.
In the end, the billing department can use the appropriate surgical CPT code and append modifier 47 to it.
Modifier 47 – Billing Guidelines
Here are some additional guidelines that you should consider while using modifier 47:
- Provider Restriction: Only the surgeon or assistant surgeon is permitted to use modifier 47. The anesthesiologist should not use this modifier.
- Anesthesia Type Restriction: Do not use this modifier for local anesthesia or for moderate sedation. It is intended only for regional or general anesthesia administered by the surgeon.
- Code Placement Restriction: Do not append the 47 modifier to anesthesia CPT codes (00100 through 01999). It must be appended directly to the surgical CPT code.
- Monitoring Prohibition: Do not use this modifier if the surgeon is simply monitoring general anesthesia that is performed by a separate provider (such as an anesthesiologist, Certified Registered Nurse Anesthetist – CRNA, resident, or intern).
Wrapping Up
Let’s summarize everything we have discussed in this guide.
- Modifier 47 indicates that during a surgery, the surgeon administered anesthesia instead of an anesthesiologist.
- The modifier is only used when general or regional sedation is performed. It is not for local anesthesia.
- Do not append this modifier to anesthesia CPT codes, 00100 through 01999. Instead, append to surgical CPT codes.
Medical billing and coding are complex processes. Even with all the guidelines and tools, denials are sure to occur. That’s why it is better to outsource medical billing services and other RCM operations to specialized companies like MediBillMD. These companies offer better results than what you can achieve with in-house teams, and at very affordable rates.
