Ophthalmology and Optometry Coding Alert

Question: One of my ophthalmologists had started a ptosis surgery but had to stop due to excessive bleeding. How should I report this--or should I just wait until he finishes the procedure and report the whole thing?


Florida Subscriber

Answer: Assuming that the ophthalmologist stopped the procedure after he had prepped the patient, you should report the surgery with modifier 53 (Discontinued procedure) appended. When you append a procedure code with modifier 53, you are telling the payer that the physician could not complete the procedure because he was concerned about the patient's health and well-being.

You can use modifier 53 only if the physician discontinues the procedure after he preps the patient for the service. Also, according to CPT, if a patient elects to cancel the procedure or service "prior to the patient's anesthesia induction and/or surgical preparation in the operating suite," you should not use modifier 53.
 
Modifier 53 also tells the payer that the ophthalmologist attempted to perform the entire procedure but could not continue for fear of harming the patient. This way, if the ophthalmologist performs the full ptosis repair a week later, the payer will know that you aren't submitting a duplicate claim, but that the ophthalmologist is trying once again to perform and complete the same procedure.