General Surgery Coding Alert

Question: Our surgeon prepped and positioned a patient for repair of a recurrent inguinal hernia. But before administration of anesthesia, the patient complained of chest pain. Cardiac monitoring revealed ST segment changes. The surgeon cancelled the procedure. How should I code this?

Virginia Subscriber

Answer: Because the surgeon cancelled the procedure before making an incision, you can’t bill for a discontinued procedure. Instead, you’ll need to report an appropriate E/M code for your surgeon’s services

If the surgeon had discontinued the procedure after the first incision, you would bill 49520 (Repair recurrent inguinal hernia, any age; reducible) and append modifier 53 (Discontinued procedure).

On the other hand, if you’re billing for the facility, not the surgeon, you should report the discontinued procedure with modifier 73 (Discontinued outpatient hospital/ambulatory surgery center [ASC] procedure prior to the administration of anesthesia) if the patient has not yet received anesthesia, or 74 (Discontinued outpatient hospital/Ambulatory surgery center [ASC] procedure after administration of anesthesia) after the provider administers anesthesia.

These modifiers are important because the facility has incurred surgery-related expenses in both cases, but less so before the providers start the procedure by administering anesthesia.