Ob-Gyn Coding Alert

A discontinued or failed procedure is one that stops before completion, usually because the patients health is or would be at serious risk if the procedure were to continue. Yet some ob/gyn physicians and coders have misconceptions about how to code the surgery and which modifier to append when a procedure is discontinued. Further, the difference between a discontinued procedure and a failed procedure that is converted to another procedure is significant when it comes to proper coding and reimbursement. Getting it wrong could cost your practice legitimate revenue, or cause you to stray into fraudulent coding.

A discontinued or terminated procedure is one that is stopped before completion. That means that surgery was stopped, the incision was closed and the patient was removed from anesthesia and taken to recovery. Causes may range from the patients excessive hemorrhaging, negative reaction to anesthesia, or the surgeon discovering a condition once surgery has begun that precludes him or her from completing the surgery. A surgery is most often discontinued when the patients well-being is at risk and continuing the surgery threatens that well-being. In such cases, modifier -53 (discontinued procedure) is appended to the procedure code.

If a procedure is attempted, and the surgeon discovers he or she must switch to a different procedure because of findings or the patients anatomy, the first procedure is considered neither failed nor discontinued it is converted.

The difference between discontinued and converted is crucial to correct coding. The use of modifier -53 depends on why the physician could not complete the procedure, as well as what else he or she actually did afterwards, says Susan Callaway, CPC, CCS-P, a North Augusta, S.C.-based independent coding consultant and educator. If the ob/gyn stopped the procedure because it was endangering the welfare of the patient, append modifier -53. But if upon starting the initial surgery, he or she converted to another procedure, the surgeon can bill only for the second one. The first procedure is not a billable item, except under very specific circumstances (see coding examples below).

Coding Examples

Questions about coding for discontinued procedures often come up when a procedure has been converted. Tracey Maille, a surgical coder for Ashtabula Clinic in Ashtabula, Ohio, offers the following example: The patient had pelvic pain with a history of endometriosis, Maille explains. The laparoscopy (58660, laparoscopy, surgical; with lysis of adhesions [salpingolysis, ovariolysis] [separate procedure]) was begun, the pelvis was visualized, and significant adhesions were discovered. It was evident that the amount of scarring posterior to the ovary and tube was significant enough for the surgeon to convert to an open procedure in order to remove the tube and ovary (58720, salpingo-oophorectomy, complete or partial, unilateral or bilateral [separate procedure]).

Maille wonders whether she can bill for both the laparoscopic lysis of adhesions and the open salpingo-oophorectomy. It was suggested to Maille that she could code for the successful salpingo-oophorectomy (58720) first, then code for the laparoscopic lysis of adhesions (58660) using the -53 modifier.

The simple answer here is no to the -53. The -53 modifier should be used only if the surgery was stopped completely. Mailles options are to code for the more expensive procedure (58720) only, or to code for both the open and the laparoscopic, appending modifier -22 (unusual procedural services) to the laparoscopy.

She should also add both a modifier -52 (reduced services) and -51 (multiple procedures) to the failed 58660. The modifier -22 would only be appended if a significant amount of work was done before switching to the open procedure. Use of modifier -22 will require comprehensive documentation to receive reimbursement. Mailles reimbursement for the laparoscopy may be as little as 25 percent of the full price for the procedure, but it is worth billing if the physician feels the coding is justified.

However, if Mailles patient had an allergic reaction to the anesthesia, and began convulsing, the procedure would be discontinued altogether. In such a case, modifier -53 is entirely appropriate. Use of the modifier will guarantee some payment for the discontinued procedure.

Callaway says modifier -53 was developed at the request of HCFA because the agency did not want to pay full price for surgeries that were stopped, yet felt that some compensation was due to the surgeon. HCFA requires that all payers manually review claims with a modifier -53. Therefore, detailed, accurate operative report documentation is extremely important when billing services with this modifier, as reimbursement is directly assigned based on the procedure documentation.

The payer calculates payment based on how much of the procedure was completed. There is no set percentage of the allowable fee; it depends on what the report shows, and how the payer calculates reimbursement for that portion of the procedure that was completed, Callaway explains.

It may be 50 percent. It may be less, or it may be more, Callaway says. For example, the patient may have crashed in the last five minutes [of a lengthy procedure], so you would be entitled to more than if the procedure failed immediately after it began.

For these reasons, Callaway recommends that coders submit the code with modifier -53 for the full amount, and let the payer decide how much to reduce it.

Theres no point taking a reduction that may be even greater than what the payer might take on their own, she says.

Note: Dont confuse modifier -53 with modifiers -73 (procedure discontinued prior to the administration of anesthesia) and -74 (procedure discontinued after administration of anesthesia). All three modifiers indicate discontinued procedures; however, modifiers -73 and -74 should be used only in ambulatory surgery centers and for outpatient hospital use, not for surgeries taking place in the hospital or the physicians own surgical facility.