Radiology Coding Alert

Question: A patient visited our outpatient radiology practice for a magnetic resonance imaging (MRI) examination of their chest without contrast. The patient started to experience severe anxiety after being inside the MRI machine. The radiologist removed the patient from the MRI machine and attempted to help the patient relax so they could continue the procedure. After several minutes, the patient was unable to resume the exam, so the radiologist cancelled the procedure for the day and will reschedule for another day.

What modifier should I append to the CPT^® code?

Arizona Subscriber

Answer: The situation you’ve described falls under a discontinued procedure rather than a reduced service. You’ll append modifier 53 (Discontinued procedure) to 71550 (Magnetic resonance (eg, proton) imaging, chest (eg, for evaluation of hilar and mediastinal lymphadenopathy); without contrast material(s)) to indicate that the radiologist stopped the chest MRI due to the patient’s anxiety.

According to Appendix A of the CPT^® code set, a physician may choose to stop a surgery or diagnostic procedure, “[d]ue to extenuating circumstances or those that threaten the well being of the patient,” and the physician may need to document that the procedure “was started but discontinued.” As a coder,

you can indicate the procedure was started but stopped by appending the procedure code with modifier 53.

At the same time, you shouldn’t use modifier 53 if the physician cancels a procedure before preparing surgery in the operating suite or the patient is administered anesthesia. In other words, if the physician was performing a surgical service, you may not bill the physician’s services in any capacity if the procedure is terminated prior to anesthesia.