Anesthesia Coding Alert

Documentation paves the way for discontinued, reduced claims success  

 Seeing an incomplete procedure on a chart can be frustrating, but it doesn’t have to equal zero reimbursement. Master modifiers 52 (Reduced services) and 53 (Discontinued procedure), and you can reap the rewards.

 Many coders get confused between modifiers 52 and 53. But the difference doesn’t have to stump you, according to Carol Pohlig, a senior coding and education specialist with the University of Pennsylvania in Philadelphia.

52 Means Less Than Expected 

 Rely on modifier 52 for an “elective” situation. In other words, your physician chooses not to go any further with the procedure because the procedure has already achieved its objective, Pohlig says. The physician might also end the procedure because she has gathered all the needed information -- there’s no medical reason to not continue with the procedure, but there’s also no medical reason to continue.

 Example: A CPT code calls for a procedure to be performed over a 24-hour period, but the physician only spends 12 hours on it, says Dianne Wilkinson, compliance officer and quality manager with MedSouth Healthcare in Dyersburg, Tenn. You can also report modifier 52 when your physician’s documentation shows that she didn’t complete all the work a code represents.

 Warning: Pohlig cautions against modifier 52 when your physician performs cases that don’t have individual CPT codes. Some coders might be tempted to append modifier 52 to an existing code if the procedure is similar to a portion of an existing procedure code. But CPT rules require you to report an unlisted-procedure code instead, such as 01999 (Unlisted anesthesia procedure[s]) or 64999 (Unlisted procedure, nervous system).

53 Often Represents Patient Safety 

 Modifier 53 (Discontinued procedure) is for situations when the anesthesiologist or surgeon sees some risk that could threaten the patient’s health if the procedure continues. The provider can cancel the procedure at any one of three points: 

 1. Preoperative visit: Your anesthesiologist completes the standard preoperative visit but believes the patient is not a good candidate for the recommended surgery. He discusses the situation with the surgeon, and the surgeon cancels the case. If the rescheduled date is far enough in the future to merit another complete pre-op consult (usually at least two or three weeks later), bill the original exam with the appropriate consultation code (99241-99245 for office/outpatient or 99251-99255 for inpatient). The second consult (when the case actually takes place) is part of the anesthesia service at the time of surgery.

 Why not 53? In the past, you would report the canceled visit with an E/M service code and modifier 53. Current CPT guidelines, however, state that you don’t use modifier 53 “to report the elective cancellation of a procedure prior to a patient’s anesthesia induction and/or surgical preparation in the operating suite.”

 2. Before induction: Mrs. Smith is prepared for surgery. Before the case begins, your anesthesiologist sees an arrhythmia when he begins monitoring her. Her surgeon cancels the case so she can be evaluated and rescheduled. Some carriers, such as Empire New York, recommend that you report the case with 01999 and append modifier 53.

 3. After induction: Your anesthesiologist induces Mr. Jones but sees a sudden drop in blood pressure. He advises the surgeon that the case should not proceed. He reverses the anesthesia, and Mr. Jones transfers to the intensive care unit or other area for stabilization and further tests. You can report either 01999 with modifier 53 again or the appropriate anesthesia code (based on the planned procedure) and modifier 53.

Outpatient Options Change Your Coding

 In an outpatient facility setting, you use a separate set of modifiers for discontinued and incomplete procedures, Pohlig says: 73 (Discontinued outpatient procedure prior to anesthesia administration) and 74 (Discontinued outpatient procedure after anesthesia administration). Report these modifiers based on whether your physician stopped the procedure before or after the patient received anesthesia.

 Note: You can submit modifier 73 for discontinued cases before anesthesia administration, but that doesn’t apply to modifiers 52 and 53. You can report modifiers 52 or 53 only if the surgeon began the procedure -- including anesthesia administration. What if the patient receives anesthesia but your anesthesiologist stops the case before actually doing anything? You append either modifier 73 or 74, depending on whether induction has taken place.

Submit Complete Documentation 

 In the past, Pohlig says, she recommended that claims with modifiers 52 or 53 should “drop to paper” so you could submit a written explanation with the claim. But in the age of HIPAA and electronic standards, you must bill electronically first.

 Once you bill electronically with either modifier 52 or 53, Pohlig says, the carrier will request more information. “If your physician is documenting properly, the anesthesia note should contain all the information the carrier needs,” she says.

 “If you had a failed procedure, the record should state why and what failed,” says Lisa Center, quality review coordinator for the Freeman Health Center in Joplin, Kan. And if your physician discontinued the procedure due to the patient’s condition, the record should detail what factors prevented the procedure from going forward.