Urology Coding Alert

Hint: Specific details will help bolster your case.

No matter how many times a surgeon performs a procedure, he never knows exactly what might happen – or what unexpected problems or complications might surface. When an issue leads to the surgeon or another provider (such as the anesthesiologist) canceling the procedure, you might need to append modifier 53 (Discontinued procedure) to the claim. Keep these guidelines in mind before submitting to the insurer.

Verify That Modifier 53 Is Merited

According to CPT^® coding guidelines, you can append modifier 53 when a physician terminates a procedure “due to extenuating circumstances or those that threaten the well-being of the patient.” Modifier 53 indicates that an unexpected problem beyond the physician’s or patient’s control necessitated ending the procedure before it was complete.

Caveat: Pay attention to the additional note in its descriptor, which states that “This modifier is not used to report the elective cancellation of a procedure prior to the patient’s anesthesia induction and/or surgical preparation in the operating suite.” In other words, before you consider modifier 53, know that the procedure was not stopped because the physician or patient elected to not continue; the physician was forced to do so because of unforeseen circumstances.

Plus: “Due to extenuating circumstances or those that threaten the wellbeing of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued,” according to Appendix A in the CPT^® manual. “This circumstance may be reported by adding modifier 53 to the code reported by the individual for the discontinued procedure.”

Consider this example from Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology, State University of New York Stony Brook:

A urologist is performing a transurethral resection of the prostate gland (TURP), which is normally reported with 52601 (Transurethral electrosurgical resection of prostate, including control of postoperative bleeding, complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included)). The patient develops a cardiac arrhythmia which requires termination of the procedure for the well-being of the patient before completion of the TURP. In this scenario, add modifier 53 to 52601 to indicate to the payer that the procedure was discontinued. Report ICD-10-CM diagnosis I49.8 (Other specified cardiac arrhythmias).

Also important: If the case is discontinued for reasons out of the provider’s control, you can append modifier 53 to the expected procedure code and receive the applicable physician fee whether or not sedation was given, says Glenn D. Littenberg, MD, MACP, FASGE, AGAF, a former CPT^® Editorial Panel member in Pasadena, California.

Always Submit Clear Documentation

Simply adding modifier 53 to a claim does not provide the payer with enough information to know how to correctly reimburse you. That means you need to submit adequate supporting documentation for reporting modifier 53. You need notes stating that the physician actually started the procedure, why it was medically necessary to discontinue the procedure, and what percentage of the procedure your urologist did perform before discontinuing.

Look for these kinds of details in the surgeon’s documentation as clues that modifier 53 might apply:

• The patient develops a contraindication and the procedure must be discontinued for patient health reasons and well-being
• The provider cannot continue the procedure for some reason (for example, surgeon cut his hand)
• The equipment is not working properly, and the procedure must be canceled (for example, laser is not working correctly).

If you can’t find documentation of any of these situations, modifier 53 might not be appropriate, Ferragamo says.

CMS takes requirements a step further, expecting the operative report and/or supporting documentation to include:

• Reason for termination of surgery
• Services actually performed
• Supplies actually provided
• Services not performed that would have been performed if surgery had not been terminated
• Supplies not provided that would have been provided if the surgery had not been terminated
• Time actually spent in each stage, e.g., pre-operative, operative, and postoperative
• Time that would have been spent in each of these stages if the surgery had not been terminated
• CPT^® and HCPCS codes for procedure had the surgery been performed

Don’t Confuse 53 with 73 or 74

The reporting rules change when you’re billing for an outpatient hospital or ASC facility. Modifier 53 should only be reported by individual providers for their operative services. The correlating modifier when billing for an outpatient facility for discontinuation prior to anesthesia is modifier 73 (Discontinued out-patient hospital/ambulatory surgery center (ASC) procedure prior to the administration of anesthesia).

In cases when the service is discontinued after the anesthesia is administered, you’ll instead report modifier 74 (Discontinued out-patient hospital/ambulatory surgery center (ASC) procedure after administration of anesthesia) for the facility billing. Remember that both modifiers (73 and 74) are only used to bill for the facility and not for the physician’s services.