Ophthalmology and Optometry Coding Alert

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 during the postoperative period). Remember, when modifier -78 is appended, that procedure's global period doesn't take effect.

Use Codes That Apply to Discontinued Procedures

In a second example, the physician was able to remove the cataract but was not able to insert the IOL. A code exists in CPT to describe that procedure: 66850 (Removal of lens material; phacofragmentation technique [mechanical or ultrasonic] [e.g., phacoemulsification], with aspiration), so you should report 66850 with -RT (Right side) or -LT (Left side) instead of the code for the procedure that was originally intended (66984).

"The American Academy of Professional Coders states that when a procedure is discontinued, you should bill for the portion of the surgery that was actually completed (if there is a code that encompasses what was done)," says Catherine Hollis of the Atlanta Ophthalmology Association. When the physician brings the patient back to insert the IOL, you would report 66985 (Insertion of intraocular lens prosthesis [secondary implant], not associated with concurrent cataract removal) with modifier -58 (Staged or related procedure or service by the same physician during the postoperative period).

Identify 'More Than 1 Session' Procedures

Some codes, such as those for most eye and ocular adnexa laser procedures, have multiple-session guidelines that disqualify use of modifier -53 or -58. When a code's descriptor specifically states "one or more sessions," the procedure code should be reported only once for the entire defined treatment period, regardless of the number of sessions necessary to complete the treatment, according to Principles of CPT Coding, published by the AMA.

For example, an ophthalmologist performs laser treatment of the patient's left choroid, 67220 (Destruction of localized lesion of choroid [e.g., choroidal neovascularization]; photocoagulation [e.g., laser], one or more sessions), and is forced to discontinue the procedure when the patient becomes unable to tolerate it. The patient returns one week later to continue the treatment, but again the physician is unable to complete the procedure due to the patient's discomfort. Finally the ophthalmologist completes the procedure in a third session. Regardless of the number of sessions it took to complete this procedure, you would report 67220-LT only once because its descriptor states "one or more sessions."

In another example, an ophthalmologist performs a cataract extraction 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 develops a vitreous bulge after the ophthalmologist has removed the cataract. Rather than risk vitreous loss, the physician decides against inserting the IOL in this session.

If the ophthalmologist then implants the IOL within the 90-day global period (which is most common), you would append modifier -58 to 66985 (Insertion of intraocular lens prosthesis [secondary implant], not associated with concurrent cataract removal) to indicate a staged procedure.

By reporting the cataract extraction-only code for the first procedure, and not the code for cataract surgery with IOL implant with modifier -53, you'll have an easier time determining how to code the second claim.