Ophthalmology and Optometry Coding Alert

Question: A patient presented with difficulty seeing the television, and our physician detected a cataract during a comprehensive examination. They agreed on surgery so he performed an A-scan, and the surgery was scheduled for later that month. Just before the scheduled surgery time the patient called to cancel because of a family emergency. Does modifier -53 apply?

Colorado Subscriber

Answer: Part of the difficulty coders have with modifier -53 (Discontinued procedure) comes from the interchangeable use of the words "cancelled" and "discontinued" by surgeons when identifying circumstances that may warrant the appendage of modifier -53. A discontinued procedure, the descriptor for modifier -53, implies the procedure was stopped after having been started.

What constitutes "starting" a procedure can also be confusing because it is not clear the preoperative services are not considered the onset of the procedure itself. The actual operative part of the global surgical package must have started in order for the procedure to be discontinued.

Preoperative services, which are considered part of the surgical package but not part of the procedure itself, include an assessment of the risks and benefits of surgery, a medical evaluation of the patient until the patient is declared safe for surgery, the identification of medical risks, and identification of any contraindications for surgery. So if the ophthalmologist examined the patient before beginning the surgical preparation and deemed the patient unfit for surgery, this decision is considered preoperative, so the code is not subject to modifier -53.

To identify a "discontinued procedure," check if the patient was administered anesthesia. If the answer if yes, the procedure has "officially" started, making modifier -53 an effective appendage. If the answer is no, modifier -53 does not apply.