# Aborted/discontinued procedure



## daboronda (Sep 17, 2012)

How would this be coded or is it as I think, not billable? Thank you for your input.

Lumbar discography (aborted secondary to vasovagal episode with loss of consciousness and enuresis)

Patient was consented, prepped and draped referral provocative lumbar discography.  He had received clindamycin 900 mg IV without incident.  We were about to start the procedure when he reported that he was "not feeling well".  His heart rate initially was normal but started becoming bradycardic going as low as 32.  He had loss of consciousness secondary to bradycardia and hypotension (75 over 47).  He had loss of consciousness for less than 30 seconds. 

We immediately administered glycopyrrolate 0.4 mg IV bolus and opened up his IV fluids to wide open.  His heart rate immediately increased to 104.  He regained consciousness.  We rolled him on his back and elevated his legs and continued to give IV fluids.

His 1st pressure after return of consciousness was 91/54.  He maintained satisfactory oxygenation throughout.  His subsequent vital signs were heart rate 102, blood pressure 96/49 and heart rate 99, blood pressure 115/58.  He remained stable.

I contacted his primary care physician to discuss the case.  He agreed with me that patient should be transported to the emergency room for evaluation.  We contacted 911 and had an emergency crew sent to deliver him to the emergency room.  Again, patient remained stable after his initial loss of consciousness.  At no point did he report dyspnea or chest pain.

I called the emergency room to give report but was put on hold indefinitely and was not able to finish my report as I was continuing to help with his monitoring.

Assuming he is okay in the emergency room, I would suggest he has a stress test to evaluate for silent ischemia from DM.


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## aaron.lucas (Sep 18, 2012)

You should be able to bill with modifier -53, the patient was under anesthesia, prepped and ready on the table, then the problems started.  That would be correct use of -53 as far as I'm concerned.  Just not sure if you would be able to bill the radiology code, or just the injection with -53?  Anybody know the answer to that?


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## dwaldman (Sep 18, 2012)

The radiology code would not be reported. 62290-53 modifier only. Box 19 would need on claim form the following statment: documentation available upon request.  Here is documentation requirements of WPS Medicare J5/could check documentation requirements of the payer you are billing if available:

Definition
Indicates the physician elected to terminate a surgical or diagnostic procedure due to the patient's well-being.
Appropriate Usage
A discontinued procedure after induction of anesthesia 


Supporting documentation should:
be available upon request 
state the procedure was started 
why the procedure was discontinued 
state the percentage of the procedure was performed


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## daboronda (Sep 18, 2012)

Thank you for your replies. 
I queried the doctor further and he was just about to administer anesthesia when this happed. 
I did review modifier 53 originally and was thinking this was only after anesthesia. I missed the and/or surgical prep.
Thank you again.


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## dwaldman (Sep 18, 2012)

As seen below from AMA CPT Network, they state the physician reports the planned procedure but that is typically limited to one code. That is why I stated the supervision and interpretation CPT 72295 would be secondary to the injection procedure for discography 62290 and thus not listed. I tried to confirm the CPT definition and was trying confirm if they state it is required to be after induction of anesthesia or not. I have the resource book, Coding with Modifiers. Will have to review further. We typically take the easy approach and unless there was incision/injection we don't attempt to report with modifier 53.


Question 

Please provide the definition and illustration of Modifier 53. 

Answer 

Following is the definition and illustration ofModifier 53, Discontinued Procedure:

Under certain circumstances, the physician may elect to terminate a surgical or diagnostic procedure. Due to extenuating circumstances or those that threaten the well being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued. This circumstance may be reported by adding the modifier 53 to the code reported by the physician for the discontinued procedure. Note: This modifier is not used to report the elective cancellation of a procedure prior to the patient's anesthesia induction and/or surgical preparation in the operating suite. For outpatient hospital/ambulatory surgery center (ASC) reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for ASC hospital outpatient use).

Modifier 53 is used for physician reporting purposes.It is used to report circumstances when patients experience unexpected responses (eg, arrhythmia, hypotensive/ hypertensive crisis) that cause the procedure to be terminated. ASC policy requires documented narrative regarding how far the procedure had progressed at the point of termination. 

Modifier 53 differs from 52 (which describes a procedure that was reduced at the physician's discretion) in that a patient's life-threatening condition precipitates the terminated procedure.Modifier 53 is not used to report elective cancellation of procedures prior to anesthesia induction or surgical preparation in the surgical suite, including situations where cancellation is due to patient instability. 

For outpatient hospital/ASC facility reporting, refer to modifiers 73 and 74 in the list of ASC-approved modifiers.

Illustration of Modifier 53

Following anesthesia induction, the patient experiences an arrhythmia that causes the procedure to be terminated. The physician reports the code for the planned procedure with the 53 modifier appended.


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