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. Which anesthesia code and modifier I should use to describe this?

Answer: Start by checking whether your payers have specific guidelines for reporting canceled cases. If the physician cancels the procedure after the patient is prepared for surgery but before induction begins, the payer may ask you to report 01999 (Unlisted anesthesia procedure[s]) with modifier 53 (Discontinued procedure). Other payers might require the correct anesthesia code for the intended procedure plus modifier 53.

Note: The full definition for modifier 53 indicates not to report it for the elective cancellation of a procedure prior to induction. Some insurance companies, however, may request the modifier despite that direction.

Include reports and additional notes in box 19 or the electronic equivalent (such as "canceled before induction, but after preparation").

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

Heads up: If the service 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).

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.