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Modifier Coding Alert

You Be the Coder:

Discover How Modifier 22 Relates to Anesthesia Modifiers ZA and ZC

Question: Why are my claims being denied when I use modifier ZC with anesthesia services?

California Subscriber

Answer: You should use modifier 22 (Increased procedural services) and physical status modifier P4 (A patient with severe systemic disease that is a constant threat to life) instead of modifiers ZA (Anesthesia procedures complicated by unusual position or surgical field avoidance) and ZC (Anesthesia complicated by extracorporeal circulation), respectively. ZA, ZC, and 14 other modifiers, specifically used by Medi-cal Insurance in California, were replaced in California as of March 1, 2011.
Refer to for a complete list of the modifiers that were replaced by HIPAA compliant HCPCS modifiers to comply with the provisions of HIPAA of 1996, Public Law 104-191, Code of Federal Regulations, Title 45, Section 162.1000.
Rather than using modifier ZA, now you’ll use modifier 22, which indicates that the work required to complete a procedure or service took substantially more time than typically required. Some reasons for taking more time are an increased intensity, experienced technical difficulty, or the length of time of the procedure or service. The rule of thumb according to CPT® Guidelines is for the time is that your provider must spend at least 50 percent more time and/or effort than normal before you can use modifier 22. See the article “Pump Up the Notes When Using Modifier 22” in Volume 1, Number 2 of Modifier Coding Alert for more on using modifier 22.
Along with the replacement of modifier ZC by physical status modifier P4, there are five other P modifiers:
  • P1 (A normal healthy patient)
  • P2 (A patient with mild systemic disease)
  • P3 (A patient with severe systemic disease)
  • P4 (A patient with severe systemic disease that is a constant threat to life)
  • P5 (A moribund patient who is not expected to survive without the operation)
  • P6 (A declared brain-dead patient whose organs are being removed for donor purposes).
The physical status modifiers identify levels of complexity of the anesthesia services, and are reported in conjunction with anesthesia services codes when appropriate. 
These six levels are included in the Anesthesia guidelines of the CPT® codebook to distinguish among various levels of complexity of the anesthesia service provided. Other modifiers located in Appendix A of the CPT® codebook may also be appropriate. These six levels are consistent with the American Society of Anesthesiologists (ASA) ranking of patient physical status, which can also be found at the ASA web site
Beware: Medicare doesn’t pay for physical status modifiers.