Neurosurgery Coding Alert

Question: A patient was scheduled to have an anterior cervical discectomy and fusion (ACDF), but it was cancelled in the operating room (OR) prior to the patient receiving anesthesia. Should I bill out for the procedure using modifier 53?

Mississippi Subscriber

Answer: Since the provider had not initiated the procedure, you would not want to bill out 22551 (Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2) to the insurance company with a modifier 53 (Discontinued procedure) attached. However, it is appropriate to report an evaluation and management (E/M) service, if the provider performs one, and obtain reimbursement from the payer for the physician's time in managing the patient up to the point of procedure cancellation.

If the procedure had begun (defined as skin incision made), you would want to include a secondary diagnosis, if applicable, explaining the reason for the terminated procedure. For instance, if a patient goes into cardiac arrest in the middle of an ACDF, you will want to include code I97.711 (Intraoperative cardiac arrest during other surgery). You will want to submit this claim both electronically (for timely filing) and on paper to justify the use of modifier 53 with code 22551. A brief explanation outlining the reason for discontinuation and the extent of prep performed prior to surgery will be sufficient.

In this case, an intraoperative secondary code is not applicable since the procedure had not begun at the time of termination.