Urology Coding Alert

Hint: Timing is everything with this modifier.

Adding modifier 53 (Discontinued procedure) to claims doesn’t happen every day, which can make some coders a little less confident in submitting it. If that sounds familiar, you’ve got no worries – we’ve collected urology-specific scenarios from our experts to help keep you on track.

Explanation: “The 53 modifier is used when the procedure was started and then is terminated because of extenuating circumstances,” says Suzan Hvizdash, CPC, physician educator for the University of Pittsburgh and past member of the American Academy of Professional Coders National Advisory Board. That is, the physician intended to provide the complete service but--because of unusual or complicating circumstances threatening the patient’s well-being--he was unable to do so.

Scenario 1: The urologist started an ESWL to fragment a ureteral stone but because of poor sonographic vision he aborted the procedure and changed to fragmenting the stone via ureteroscopic lithotripsy. He documented code 52353. Does this merit modifier 53?

Scenario 1 solution: Although the surgeon planned and initiated extracorporeal shockwave lithotripsy (ESWL), the ESWL could not be completed and you should only code for the procedure that accomplished and completed the intended surgery. Therefore, do not report 50590 (Lithotripsy, extracorporeal shock wave). Instead, submit code 52353 (Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with lithotripsy [ureteral catheterization is included]) because it represents the procedure that completed the intended surgery.

The case does not justify modifier 53. The urologist changed from one procedure to another because of the circumstances, but did not discontinue surgery completely. Modifier 53 represents a complete discontinuation or termination of surgery during that encounter because of a threat to the patient’s well-being or other extenuating circumstances such as equipment failure.

Scenario 2: My urologist started a laparoscopic prostatectomy. Mobilizing the bladder revealed a high prostate with limited working space for dissection. Given the patient’s morbid obesity, limited working space, and the patient’s age, the urologist determined it was best to abort the procedure.

Scenario 2 solution: In this case, submit 55866 (Laparoscopy, surgical prostatectomy, retropubic radical, including nerve sparing, includes robotic assistance, when performed) with modifier 53 to indicate that the urologist aborted the procedure for the patient’s well-being. His terminating the procedure because of extenuating circumstances supports the modifier’s use.

Scenario 3: The urologist terminated a Targis, microwave thermotherapy, procedure due to mechanical problems. The patient will return on a later date so the urologist can complete the surgery. Do you bill the thermotherapy procedure with modifier 53, or should this just be written off?

Scenario 3 solution: Yes, this qualifies for modifier 53. You should submit 53850 (Transurethral destruction of prostate tissue; by microwave thermotherapy) and append modifier 53 to indicate that your physician had to terminate the procedure before he was able to complete it.

Many payers remove the global-period restrictions on a procedure if you append modifier 53. Therefore, when the patient undergoes surgery again to complete the procedure, you can once again report 53850 without a modifier if performed within the initial 90-day global period of the initial thermotherapy.

Another important point: You can only use modifier 53 when anesthesia has already been initiated. If the physician cancels a procedure prior to anesthesia, you cannot bill the surgical procedure code even with modifier 53 appended. Instead, if the physician performs and documents a history, an exam, and/or some level of medical decision-making (two of the three), you should bill the appropriate inpatient or outpatient E/M service code.

One more tip: Be careful to not confuse a discontinued service and modifier 53 with a procedure that should be reported with modifier 52 (Reduced services). Modifier 52 normally applies when the physician plans or expects a reduction in services as represented by the CPT^® code. This reduction of services must occur by choice (by either the physician or patient) rather than necessity (which falls under modifier 53). Reporting modifier 52 tells the payer that the urologist completed the procedure, but not the full procedure indicated by the code descriptor.

Example: If a descriptor specifies a bilateral procedure, such as 55845 (Prostatectomy, retropubic radical, with or without nerve sparing; with bilateral pelvic lymphadenectomy …), but no code describes an equivalent unilateral procedure, and the physician provides the service on one side only, modifier 52 is appropriate. Verify that there is no designated CPT® code to describe the lesser procedure before you submit the “higher level” code with modifier 52.