Urology Coding Alert

Make sure you’ve got documentation to support your modifier.

Finding your stride as a surgical coder means having all the tools at your disposal to code a wide variety of clinical situations. If you come across a discontinued procedure that sends your workflow to a screeching halt — don’t fret. Analyzing a few fine details within the report, and subsequently appending the appropriate modifier, will get you back on your feet and running in no time. This means knowing how to handle procedures discontinued before — and after — the administration of anesthesia.

In fact, according to a recent audit issue posted by Part B Recovery Audit Contractors (RAC) Cotiviti, reviewers are looking at claims for procedures that are discontinued before anesthesia administration. “Modifiers provide a way for hospitals to report and be paid for expenses incurred in preparing a patient for surgery and scheduling a room for performing the procedure where the service is subsequently discontinued,” Cotiviti said in the audit details.

Get up to speed with some pertinent info on which discontinued procedure modifier you should, and should not, consider in a given surgical scenario.

Consider This Scenario

Suppose your urologist begins a retroperitoneal lymphadenectomy (38780, Retroperitoneal transabdominal lymphadenectomy, extensive, including pelvic, aortic, and renal nodes (separate procedure), but the urologist must discontinue the surgery because the patient’s health becomes endangered. What is the correct modifier to append in this situation?

The answer will depend on where the service took place, and whose billing you’re handling: the urologist or an ambulatory surgical center (ASC).

Assuming you’re billing for the urologist, the appropriate modifier is 53 (Discontinued procedure). You’ll use modifier 53 when the physician begins a procedure or diagnostic test and then decides to terminate the surgery due to extenuating circumstances or those that threaten the well-being of the patient. So, you would append modifier 53 to the CPT^® code of the procedure that was discontinued — and this applies for the physician fee as long as the procedure was started but only partially completed, says Glenn D. Littenberg, MD, MACP, FASGE, AGAF, former CPT^® Editorial Panel member in Pasadena, California.

Avoid Modifiers 73, 74 in Pro-Fee Coding

There are two modifiers which you should avoid if you’re coding and billing for the physician’s portion of the procedure. However, in instances in which you’re coding for an outpatient facility or ASC, and surgery is terminated prior to or following the administration of anesthesia, you’ll report one of the following respective modifiers:

• Modifier 73 (Discontinued out-patient hospital/ ambulatory surgery center (ASC) procedure prior to the administration of anesthesia)
• Modifier 74 (Discontinued out-patient hospital/ ambulatory surgery center (ASC) procedure after administration of anesthesia)

Note: These modifiers are applicable to Outpatient Prospective Payment System (OPPS) billing. If you’re coding for a physician’s surgical fee that takes place within an ASC or outpatient facility, you will not use these modifiers.

Keep in mind that you would not use modifier 53 if the procedure was cancelled for elective reasons before surgery began. Instead, you should reserve it for times when the patient’s condition warrants halting the service after the surgical procedure has begun.

Know When, When Not to Consider Modifier 53

As outlined in the previous example, when a surgeon has to terminate a surgical procedure following the administration of anesthesia, you’ll append modifier 53. However, submitting modifier 53 alone does not provide the payer with enough information to know how to correctly reimburse the physician, so make sure you submit the supporting documentation. The documentation must state that the physician actually started the procedure, why it was medically necessary to discontinue the procedure, and the extent of work performed prior to termination. If acceptable by the carrier, you may choose to submit this claim on paper with all the relevant documentation to justify the use of modifier 53.

However, unlike modifier 73 in a facility setting, you should not append a modifier to a physician’s portion of the surgery if the surgeon elects to terminate the procedure prior to the administration of anesthesia. Modifier 73 is intended to reimburse the facility for the work and resources used in preparing the operating room (OR) for the surgery.

Outline Key Differences Between 52, 53

Your last point of consideration is making the proper distinction between modifier 53 and modifier 52 (Reduced services). As you’ll see based on the following descriptions, one of the fundamental differences between modifiers 52 and 53 has to do with whether the surgeon completes the procedure. In most instances, if the health of the patient is not compromised or there are no extenuating circumstances (i.e., equipment failure), there may be no justifiable reason to terminate a procedure. However, a physician may opt to limit or reduce the work involved for clinical reasons. In these scenarios, modifier 52 is the correct modifier to append to the surgical code. Round out your knowledge with the following modifier descriptions:

Modifier 53: “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.”

Modifier 52: On the other hand, 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 physician completed the procedure, but not the full procedure as indicated by the code descriptor.