Gastroenterology Coding Alert

Question: How can I tell when a procedure should be coded as discontinued? For example, if my gastroenterologist 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 physicians- interchangeable use of the words -cancelled- and -discontinued- when identifying circumstances that may warrant appending modifier 53.

To use 53, you have to be sure the physician stopped the procedure after having 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 for a procedure to be classified -discontinued.-

Catch this: But performing preoperative services 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 his examination of the patient before beginning the surgical preparation and determines the patient is unfit for surgery, payers would consider this decision preoperative, so the code is not subject to modifier 53.

Hint: To identify a true discontinued procedure, check whether the patient had 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 ASC coders: If the physician ends the procedure after the induction of anesthesia when performing the procedure in an ambulatory surgical center owned by the gastroenterologist, you should append modifier 74 (Discontinued outpatient procedure after anesthesia administration) to the procedure facility code.