Question: I’ve recently begun coding for an ambulatory surgical center after several years working as a physician coder. If the surgeon has to cancel a procedure after anesthesia due to adverse patient reactions, how should I report the facility service? Does modifier 53 still apply?
Washington, D.C., Subscriber
Answer: You should not report modifier 53 (Dis-continued procedure) for a facility. Instead -- when reporting services in an ASC or hospital outpatient facility -- you should select either modifier 73 (Discontinued outpatient procedure prior to anesthesia administration) or modifier 74 (Discontinued outpatient procedure after anesthesia administration), depending on circumstances.
In direct response to your question, you would append modifier 74 to the code for the procedure(s) that the physician had planned to perform prior to the adverse patient reaction.
For example: A patient dies during pacemaker insertion, prior to anesthesia. In this case, the facility coder would report 33216 (Insertion of a transvenous electrode; single-chamber [one electrode] permanent pacemaker or single-chamber pacing cardioverter-defibrillator) with modifier 73.
To support using the discontinued-service modifiers, documentation should include:
• Reason for termination
• Services actually performed
• Supplies provided
• Physician time spent in each stage (preoperative, operative and postoperative).
The patient must actually be prepped and in the room where the procedure is to be performed to append modifier 73.
For example, for a patient who develops an allergic reaction to a drug administered prior to surgery, you might support the claim with a diagnosis of V64.1 (Surgical or other procedure not carried out because of contraindication) or V64.3 (Procedure not carried out for other reasons), along with a primary diagnosis to describe the precise condition or signs/symptoms that prompted the physician to forego the procedure.
Facility expenses will vary according to whether anesthesia has been administered to the patient, so you must be careful to select the appropriate modifier.
If the surgeon terminates the procedure after inducing anesthesia, CMS will pay the facility the full facility rate. Its rationale is that the facility’s resources are consumed in essentially the same manner and to the same extent as they would have been had the physician completed the surgery. Make sure you have clear and supporting documentation for the termination.
If the physician ends the procedure prior to anesthesia, CMS will make a 50 percent payment to the facility if the termination is due to the onset of medical complications after the patient has been prepared for surgery and taken to the operating room but before anesthesia has been induced.
Finally, although you should forego modifier 53 in favor of modifier 73 or 74 in places of service 22 (outpatient hospital) and 24 (ASC), you may still report modifier 52 (Reduced services) in either of these facility settings for a service "partially reduced or eliminated" at the physician’s discretion. Keep an eye on Ambulatory Coding and Payment Report for an upcoming article on how to properly use modifier 52.
