Anesthesia Coding Alert

Question: We had a patient scheduled for a colonoscopy with biopsy who experienced an episode of syncope in the pre-op area while the nurse was placing an IV. The physician cancelled the procedure, and now I need to know which anesthesia code and modifier I should use to describe this.

New Hampshire Subscriber

Answer: First, you should check with your payer to see if there are specific guidelines for reporting canceled cases. 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 (Discontinued procedure).

Warning: Although modifier 53 may not seem applicable because the full definition indicates not to report for the elective cancellation of a procedure prior to induction, some insurance companies may request the use of this modifier.

For 01999, you may need to add reports and additional notes in box 19 or the electronic equivalent (such as "canceled before induction, but after preparation").

If the procedure was canceled after induction, the surgical procedure code for this, 45380 (Colonoscopy ... with biopsy, single or multiple), crosses to 00810 (Anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum).

If the service was provided in an outpatient hospital or ambulatory surgical center, some carriers require modifier 73 (Discontinued outpatient procedure prior to anesthesia administration) or modifier 74 (Discontinued outpatient procedure after anesthesia administration).

A consultation code may be appropriate if the physician cancels the procedure based on a pre-op assessment.

Remember: You should indicate the reason for the cancellation of the surgery by reporting diagnosis codes V64.1 (Surgical or other procedure not carried out because of contraindication) and 780.2 (Syncope and collapse). Depending on when the physician canceled the case, you may also report the diagnosis for the colonoscopy.