Ophthalmology and Optometry Coding Alert

Your physician went into a procedure expecting things to proceed normally. You expected the same when the file came to you for coding, but now you see that things didn't go as planned.

Do you report the case, or was the extent of your doctor's work covered by preop care? If you file the claim, do you append modifier 53 (Discontinued procedure) or just submit the appropriate surgical code?

Read on for some expert guidance on how to handle these scenarios correctly every time.

You should report modifier 53 when a physician stops a procedure "due to extenuating circumstances or those that threaten the well-being of the patient," according to CPT's definition.

Modifier 53 describes an unexpected problem, beyond the physician or patient's control that necessitates stopping the procedure. The physician elects to discontinue the procedure because of circumstances that threaten the patient's well-being.

"Modifier 53 is for services that are discontinued for very specific reasons," explains Marcella Bucknam, CPC, CCS-P, CPC-H, CCS, CPC-P, CPC-I, CCC, COBGC, manager of compliance education for University of Washington Physicians. She suggests watching for three details:

1. The patient develops a contraindication during the procedure and the procedure must be discontinued for patient health reasons

2. The physician cannot continue the procedure for some other reason (for instance, the surgeon cut his hand)

3. The equipment is not working properly and the procedure must be stopped (such as the laser is not working correctly).

"If one of these reasons does not apply, you should not use modifier 53," Bucknam says.

Outside the guides: What if these situations don't apply to your case? Although non-Medicare payers can make their rules, Bucknam says most would direct you to append modifier 52 (Reduced services) instead of 53.

Pitfall avoidance: To apply modifier 52 instead of 53, the reduction of services must occur by choice (either the physician's or the patient's) rather than necessity. If your physician determines that the patient requires a service but at a lesser level than the complete code description indicates, or if the patient elects to cancel after the procedure has started but prior to its completion, then modifier 52 is appropriate. You might also turn to modifier 52 when the code specifies a bilateral service but the physician performs the service on only one side.

Procedures might stop at any time when the anesthesiologist or surgeon sees some risk that could threaten the patient's health if the case were to continue. Either physician can decide to stop the procedure at one of three points. Your coding will depend on the timeframe.

1. Preoperative visit: The anesthesiologist completes the standard preoperative visit but believes the patient is not a good elective surgical candidate for some reason (for example, the patient has a fever and lung congestion). He discusses the situation with your ophthalmologist, who decides to reschedule the case. If the rescheduled date is far enough in the future and requires another complete pre-op evaluation, you may be able to bill another E/M service. Be sure documentation supports medical necessity for another pre-operative evaluation.

Some carriers suggest you report a consultation code (99241-99245 for office/outpatient or 99251-99255 for inpatient) when the case is canceled before the patientreceives any anesthesia service, according to Kelly Dennis, MBA, CPC, ACS-AP, president of Perfect Office Solutions in Leesburg, Fla. In the past, you might have reported the canceled procedure with an E/M code and modifier 53 but that's no longer the case. Current CPT guidelines state that you cannot use modifier 53 "to report the elective cancellation of a procedure prior to a patient's anesthesia induction and/or surgical preparation in the operating suite." And secondly, modifier 53 is never reported with an E/M code.

2. Before induction: The hospital staff takes Mrs.Smith into the operating room. Before the surgery begins, the anesthesiologist sees an arrhythmia as he begins monitoring her. Your ophthalmologist decides to reschedule the case so the patient can be evaluated for the arrhythmia.

Check your carrier guidelines before reporting the cancellation to be sure you submit the claim correctly. "I also recommend checking state-specific carrier guidelines, as there are quite a few differences," Dennis advises. "Using modifier 53 might reduce your payment, so know what to expect."

3. After induction: The anesthesiologist induces Mr. Jones but sees a sudden drop in blood pressure. He advises your ophthalmologist that the case should not proceed. He reverses the anesthesia, and Mr. Jones transfers to the intensive care unit or other area for stabilization and further tests.

You have two coding options in this scenario. The option chosen may depend upon payer-specific instructions, Dennis says. Some carriers, such as Blue Cross/Blue Shield of Florida, allow you to report the actual code in these situations (based on the planned procedure). Other payers may prefer an unlisted procedure code with a copy of the surgical report indicating the point at which the procedure was stopped. The preferable way is to report the actual code," Dennis adds.

Two other modifiers apply to discontinued procedures, but you shouldn't need them to report your ophthalmologist's services:

• modifier 73 -- Discontinued outpatient procedure prior to anesthesia administration.

• modifier 74 -- Discontinued outpatient procedure after anesthesia administration.

"Modifiers 73 and 74 are for facility coding only," Bucknam explains. "Physicians can't use these modifiers; they would report modifier 53 (when appropriate) whether the service is inpatient or outpatient."

Final key: "If the case is canceled at any point before induction, the documentation requirements for E/M service must be met if you're to bill an E/M code," Bucknam says.

"Documentation should explain why the case was stopped and amount of work completed so the coder knows how to bill," Dennis adds. When filing your claim, don't forget the secondary diagnosis codes that help explain the reason for canceled cases:

• V64.1 -- Surgical or other procedure not carried out because of contraindication

• V64.2 -- Surgical or other procedure not carried out because of patient's decision

• V64.3 -- Procedure not carried out for other reasons.