General Surgery Coding Alert

Question: During a recent surgery, the patient developed uncontrolled bleeding, and the surgeon had to abandon the procedure. Anesthesia had already been administered. How should we bill?

North Carolina Subscriber

Answer: You do not indicate the type of surgery, but because anesthesia was administered and the operation was begun, assign the proper procedure code with modifier -53 (Discontinued procedure) appended.

When submitting the claim, include a detailed explanation of how much work was completed and the reason that the service was reduced. Include a record of the time spent giving pre- and postoperative care, as well as supplies used, and compare this to the time and supplies generally necessary to complete the procedure. Do not reduce your charges. Instead, allow the carrier to determine the appropriate reimbursement using the documentation provided.

Be careful not to confuse modifier -53 with modifier -52 (Reduced services). Modifier -52 indicates only that a procedure or service delivered was much less than that described by the closest-available CPT code. For instance, if the surgeon performed three of five components of a given procedure, report the procedure code with modifier -52 appended. In some cases, the insurer may prefer that an unlisted-procedure code (e.g., 49999, Unlisted procedure, abdomen, peritoneum and omentum) be reported rather than the "next closest" code with modifier -52. Ask your carrier before filing the claim.

Do not use modifier -52 for terminated services, except to indicate an unusual or reduced service terminated before anesthesia is given. As a general guideline, modifier -52 is appropriate if the physician plans to provide a less-than-complete service, but modifier -53 is correct if the physician must unexpectedly terminate a procedure due to unusual and/or extenuating circumstances (e.g., uncontrollable bleeding, cardiac arrest, etc.) that place the patient's well-being in jeopardy.

When reporting modifier -53 you may include a diagnosis of V64.x, which describes procedures not carried out for various reasons, to further explain the claim.

Technical and coding advice for You Be the Coder and Reader Questions provided by Marcella Bucknam, CPC, CCS-P, CPC-H, HIM program coordinator, Clarkson College, Omaha, Neb.