Modifier 23 CPT Coding
Modifer-23
Under some circumstances general anesthesia is given when normally either a local or no anesthesia is provided.
For example, performing a cystoscopy on a three-year-old child would likely require a general anesthesia, whereas the same procedure on an adult would not. Thus, use of a general anesthetic when performing a cystoscopy is an example of unusual anesthesia.
Appendix A of CPT explains: “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.”
Example: A young child patient may require anesthesia to undergo a procedure that normally does not require it.
Documentation of the medical necessity is very important (why anesthesia was necessary)
The modifier “23” should be submitted with the appropriate procedure code to report unusual anesthesia. This modifier should not be reported with procedure codes that include the term “without anesthesia” in the description or for procedures that are normally performed under general anesthesia.