Anesthesia Coding Alert

Timing is everything for reporting modifier -53

 When a surgical case is canceled, it's your job to determine whether the anesthesiologist's involvement merits reporting. Do you automatically append modifier -53 (Discontinued procedure) and submit the claim, or do you write it off and wait to code the procedure when it occurs? The answer depends on the case circumstances, so read on for tips on making that decision.

Determine Why the Case Was Canceled

Your first step in determining whether a canceled case is billable is establishing the reason for the cancellation. This can be as simple as the patient changing his mind about an elective procedure because he hasn't met his annual deductible, or as complex as sudden problems with blood pressure, cardiac function or other medical complications.

 "A case may be canceled prior to induction because the patient is not medically cleared for surgery," says Tammy Reed, anesthesia department billing manager with Oklahoma University Health Science Center in Oklahoma City. "The correct instruments or supplies may not be available, or the surgeon may have an emergency case. A case may be canceled after induction because the patient is unstable, the anesthesiologist is unable to obtain an adequate airway, or the surgeon decides for some other reason not to continue."
 
Check documentation: The surgeon should clearly document the reason for the cancellation on the patient's chart - and the anesthesia record should also contain the reason for the cancellation.
 
For example, the anesthesia record might state, "Canceled before induction but after preparation" or "Canceled after induction." Other information you should check in the chart includes the point at which the case was canceled and what type of involvement anesthesia team members had prior to cancellation.
 
Timing: "You must determine if the cancellation occurred before or after anesthesia induction," says Emma LeGrand, CPC, CCS, coding supervisor with New Jersey Anesthesia Associates in Florham Park. LeGrand advises also checking for the place of service, which she says will assist you in selecting the correct modifier if one is appropriate.

Avoid -53 for Preinduction Cancels

There are no black-and-white rules for coding anesthesia's involvement when surgery is postponed prior to the induction of anesthesia. Instead, correct coding depends in part on the carrier's guidelines and on the timing of the cancellation.
 
In most cases, the standard anesthesia fee includes any of the anesthesiologist's preoperative evaluation work before the day of surgery. But this same pre-op work might be billable if the procedure associated with it gets canceled - depending on how long it takes to reschedule the procedure and how far along the case is before cancellation.
 
If the case is canceled before the day of surgery, some anesthesia providers will review the pre-op work from the case and bill the appropriate E/M code for their services (99212-99215 for established outpatients and 99231-99233 for inpatients).
 
Take note: In the past, some coders would append modifier -53 to indicate that the care was not a standard E/M service but a preoperative case. Current CPT guidelines, however, state that this is no longer appropriate. (Part of the note with modifier -53's description in Appendix A states, "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.")
 
"Sometimes the surgeon requests a 'pre-op clearance' for high-risk patients," Reed says. "If the case is canceled based on the anesthesiologist's opinion, you can report a consultation code for the service (99241-99245 or 99251-99255). That's because it does constitute the 'request for opinion and the response back to the surgeon' of a consult and because the surgeon isn't asking the anesthesiologist to take over the patient's care."
 
Remember: It's important to note that the surgeon isn't the only medical professional who can cancel a case. LeGrand points out that the anesthesiologist could complete the preoperative assessment and decide to cancel the procedure because he thinks that the patient is not a good candidate for the recommended surgery. Again, you'll submit the claim as a consult based on the level of care.
 
LeGrand says your coding can change if the procedure is canceled after the patient has been prepared for surgery but before induction of anesthesia. She recommends coding these claims with 01999 (Unlisted anesthesia procedure[s]) along with notes explaining the reason for cancellation. But other coders believe an E/M service code is still warranted and don't have problems reporting that instead.

Consider 2 Postinduction Options

Most carriers will pay for the anesthesia service if the surgery is canceled after the induction of anesthesia. You have two options for coding these cases, depending on your carrier's preference: