Gastroenterology Coding Alert

Question: How do I tell when a procedure should be coded as discontinued? For example, if my gastroen-terologist doesn't even insert the scope, should I code the procedure with modifier -53? Or should I not code for anything at all?

New Jersey Subscriber

Answer: There is a fine line between an incomplete and a discontinued procedure, but there are some rules of thumb that can help you determine whether modifier -53 (Discontinued procedure) is appropriate.

Part of the difficulty coders have with modifier -53 comes from surgeons' interchangeable use of the words "cancelled" and "discontinued" when identifying circumstances that may warrant appending modifier -53.

To use modifier -53, you have to be sure the procedure was stopped after having been started. "Starting" a procedure can also be confusing though, because you have to separate the preoperative services from the onset of the actual procedure. In other words, the actual operative part of the global surgical package must have been started in order for a procedure to be classified "discontinued."

Performing preoperative services, on the other hand, does not constitute actually starting the operation because they are not part of the procedure itself, even though they are considered part of the surgical package. These preoperative services include an assessment of the risks and benefits of surgery, a medical evaluation of the patient until the patient is declared safe for surgery, the identification of medical risks, and the identification of any contraindications for surgery. So if the gastroenterologist only documents examining the patient before beginning the surgical preparation and determining the patient is unfit for surgery, this decision is considered preoperative, so the code is not subject to modifier -53.

To identify a true discontinued procedure, check whether the patient was administered anesthesia. If so, the procedure has officially started, making modifier -53 an effective appendage to the procedure code. If not, modifier -53 does not apply.

You may be able to code and be reimbursed for an E/M visit if the gastroenterologist has documented the patient's history and examination and decides not to sedate the patient.

For all you ASC coders: If the procedure is terminated after the induction of anesthesia when the procedure is being performed in an ambulatory surgical center owned by the gastroenterologist, you should append modifier -74 (Discontinued outpatient procedure after anesthesia administration) to the procedure code.

Clinical and coding expertise for You Be the Coder and Reader Questions provided by Linda Parks, MA, CPC, CCP, coding specialist for GI Diagnostics Endoscopy Center in Marietta, Ga.