Neurosurgery Coding Alert

Question: The surgeon was in the beginning stages of performing an L2-L3, L3-L4 arthrodesis for a patient with scoliosis. After making the incision and separating the paraspinal muscles from the vertebral column, the patient’s respiratory rate and pulse began to significantly drop. The procedure was subsequently aborted. The surgeon is requesting that I bill out for the entire procedure, including use of instrumen­tation, with modifier 53. Would this be correct?

Maine Subscriber

Answer: Based on the description of the procedure, the physician should only bill out for the primary procedure with modifier 53 (Discontinued services). Since the surgeon only performed the equivalent of a deep incision, there is no justification to code out for use of instrumentation, since none was applied. If the physician had been in the middle of, say, a pedicle fixation, then use of an instrumentation code (with modifier 53) would be appropriate.

Based on this example, the physician would only bill out for 22800 (Arthrodesis, posterior, for spinal deformity, with or without cast, up to 6 vertebral segments) with modifier 53 appended.

Submit documentation: Just as you would with modifier 22 (Unusual procedural services) and 52 (Reduced services), you will want to submit documentation to support the use of modifier 53. While some providers might wonder why this is necessary, it actually could result in significantly higher reimbursement, depending on the operative note.

Submitting modifier 53 alone does not provide the insurance company with enough information to know how to correctly reimburse the provider. Since a discontinued procedure could occur at the early stages of a surgery or after the surgeon performs the majority of work, the insurance company will require context behind the discontinuation before reimbursing the provider. Often, the operative report and a note from the office manager will suffice; but the best chance at optimal reimbursement is if the provider is able to contribute a separate note of their own explaining the situation.