End Discontinued Procedures Difficulty With These Tips
Published on Fri Feb 20, 2004
Stop modifier -53 problems before they start with thorough documentation
Modifier -53 (Discontinued procedure) is appropriate for some procedures, such as cataract surgery with intraocular lens (IOL) insertion, but carriers may reject it with procedures that require more than one session. Knowing these subtle differences will ensure correct use of modifier -53.
Medicare clearly states that a hospital should add modifier -53 to the intended procedure code, and so should physicians. CPT 2004 instructs coders on when to use modifier -53: "Under certain circumstances, a physician may elect to terminate a surgical or diagnostic procedure. Due to extenuating circumstances or those that threaten the well-being of the patient, it may be necessary to indicate that a surgical (diagnostic or therapeutic) procedure was started but discontinued."
The key here is that the physician makes the decision during the procedure based on the patient's status, says Karen J. Gillett, RHIT, CPC, coding analyst at Bend Memorial Clinic in Oregon. And the operative report should clearly document why the procedure had to be discontinued or terminated. Do not report elective cancellation of a procedure. The CPT Assistant, May 1997, states: "Added in CPT 1997, this modifier describes discontinued procedures and is appended to a procedure code to report circumstances when patients experience unexpected responses (e.g., arrhythmia or hypotensive/hypertensive crisis) that cause the procedure to be terminated. ... you would not append modifier -53 to report elective cancellation of procedures prior to anesthesia induction or surgical preparation in the surgical suite, including situations where cancellation is due to patient instability."
Document Any Completed Procedures In addition to dictating why the procedure had to be discontinued, the physician should note all procedures performed including the retrobulbar block and any incisions or other work that he performed. That documentation will determine how you report the procedure, and your carrier will want to review it if you do submit your claim with modifier -53.
Using modifier -53 may or may not reduce your ophthalmologist's fee, depending on how your carrier processes payment based on your documentation. If it's reduced, there's no prescribed reduction amount. For example, an ophthalmologist begins phacofragmentation cataract surgery with intraocular lens (IOL) insertion 66984 (Extracapsular cataract removal with insertion of intraocular lens prosthesis [one-stage procedure], manual or mechanical technique [e.g., irrigation and aspiration or phacoemulsification]).
The patient is sedated then the surgeon performs a retrobulbar block, makes the incision and starts removing the cataract, but the patient starts moving on the table. Increasing IV sedation is ineffective, so the surgeon discontinues the procedure. Report 66984-53.
If your ophthalmologist returns to the operating room within the 90-day global to finish what he started, report 66984 again, but append modifier -78 (Return to the operating room for a related procedure [...]
