Anesthesia Coding Alert

Documentation and timing of cancellation make or break modifier 53.

When your anesthesiologist or the surgeon sees some risk that could threaten the patient's health if the procedure continues, you might turn to modifier 53 (Discontinued procedure). Payers sometimes balk at reimbursing these claims, however, so let our experts help point you in the right direction for reimbursement.

Conquer Electronic Filing Challenges

In the past, you may have been told to submit paper claims reporting modifier 53 so you can append a written explanation with the claim. Now, in the age of HIPAA and electronic standards, you must first bill electronically, says Carol Pohlig, BSN, RN, CPC, ACS-FP, ACS-GI, senior coding and education specialist in the office of clinical documentation for Hospital of the University of Pennsylvania's department of medicine.

Once you bill electronically with modifier 53, the payer might request more information. "If your physician is documenting properly, the anesthesia note should contain all the information the carrier needs," Pohlig says.

Note: If you had a failed procedure, the record should state why and what failed. If your physician discontinued the procedure due to the patient's condition, the record should detail what factors prevented the procedure from going forward.

Verify the Timing of Cancellation

Knowing exactly when the case was canceled in terms of the anesthesiologist's work will help guide your code choices.

Example 1: If the physician cancels the procedure after the patient is prepared for surgery but before induction, your payer may ask you to report 01999 (Unlisted anesthesia procedure[s]) with modifier 53. Check the payer's guidelines before automatically reporting modifier 53, however. Submitting modifier 53 might not seem appropriate because the full descriptor indicates not to report for the elective cancellation of a procedure prior to induction, but some insurance companies might request 53.

Example 2: If the physician cancels the procedure after induction, the case technically became a surgical procedure. Determine the correct surgical code, such as 45380 (Colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiple) for a colonoscopy with biopsy. Then cross to the correct anesthesia code, such as 00810 (Anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum) in this example.

If the cancelled procedure took place in an outpatient hospital or ambulatory surgical center, some payers require modifier 73 (Discontinued outpatient procedure prior to anesthesia administration) or modifier 74 (Discontinued outpatient procedure after anesthesia administration). In those situations, append modifier 73 or 74 to the anesthesia code instead of modifier 53 because modifiers 73 and 74 are specifically for outpatient hospital use.

Include the Correct Diagnosis

Indicate the reason for cancellation by reporting the appropriate diagnosis code or codes.

For example, a patient experiences syncope while still in the pre-op area before her procedure. You could include diagnosis codes V64.1 (Surgical or other procedure not carried out because of contraindication) and 780.2 (Syncope and collapse) on the claim. Depending on when the physician canceled the case, you may also report the diagnosis for the scheduled procedure.