Urology Coding Alert

Hint: If the urologist doesn’t even see the patient, you can’t report a procedure.

Not every urological procedure goes according to plan, and in some cases, you may need to tell the insurer that a service was discontinued before the urologist could complete it. Although your coding options may seem straightforward at first, there are several caveats that could lead you to the wrong choice.

Check out these four examples so you can identify the correct modifier and collect for your halted procedures.

Use Modifier 53 When Urologist Discontinues Procedure

When your urologist decides to terminate a surgical or diagnostic procedure due to extenuating circumstances or those that threaten the well-being of the patient, you may need to add modifier 53 (Discontinued procedure) to your claim. However, you must meet certain criteria first:

• In most cases, the patient should already be sedated before the urologist decides to discontinue the procedure.
• The actual surgery must have begun — the service can’t be discontinued during patient prep.
• You have adequate supporting documentation that you can send with the claim to demonstrate the portion of the service the urologist performed, along with the reason the service was discontinued.

Example 1: Suppose the patient is prepped for surgery and put under general anesthesia, after which the urologist begins performing a transurethral resection of the prostate gland (TURP). The patient’s heart rate falls to 39 beats per minute and the anesthesiologist is unable to get it to rise to a safe level. The urologist discontinues the procedure before addressing the affected portion of the prostate, removes the resectoscope, and takes the patient to the recovery room.

In this situation, you’ll report 52601-53 (Transurethral electrosurgical resection of prostate, including control of postoperative bleeding, complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included)). You should submit the urologist’s documentation with the claim, as well as ICD-10-CM diagnosis R00.1 (Bradycardia, unspecified) to denote the patient’s slow heartbeat.

Skip 53 for ASC Site of Service

The urologist’s coder should report modifier 53, but the ambulatory surgery center (ASC), where the service is being performed, would not report modifier 53. If a discontinued procedure occurs, then the ASC (facility) coder should report the appropriate code with either modifier 73 (Discontinued out-patient hospital/ ambulatory surgery center (ASC) procedure prior to the administration of anesthesia) or 74 (Discontinued out-patient hospital/ambulatory surgery center (ASC) procedure after administration of anesthesia) appended.

Example 2: A patient presents for a retroperitoneal transabdominal lymphadenectomy and is prepped and anesthetized. The urologist makes an incision in the patient’s abdomen, but at that point, the patient’s blood pressure falls to 80/50 and the surgeon discontinues the procedure.

In this case, the urologist will report 38780-53 (Retroperitoneal transabdominal lymphadenectomy, extensive, including pelvic, aortic, and renal nodes (separate procedure)), while the ASC will report 38780-74. Use the appropriate low blood pressure diagnosis code with the claim, such as R03.1 (Nonspecific low blood-pressure reading).

Prior to Anesthesia, Don’t Report Surgical Code

In most cases, payers won’t accept claims with modifier 53 appended unless the patient has been anesthetized. If your urologist discontinues the procedure before anesthesia has begun, you shouldn’t report a surgery code. How to code this situation will depend on what the urologist actually did. If they examined the patient that day, you may be able to report an evaluation and management (E/M) code (such as established patient office or other outpatient codes 99212-99215). If not, you shouldn’t report anything for the service.

Example 3: The patient presents to the ASC for a transurethral destruction of prostate tissue by microwave thermotherapy. The ASC staff starts an IV line and administers a COVID-19 test, which comes back positive. The urologist did not yet see the patient that day. The physician documents the fact that the procedure was halted and notes that it will be rescheduled once the patient tests negative for COVID-19.

In this case, the urologist should not report anything for the service since they did not see the patient that day. The ASC should report 53850-73 (Transurethral destruction of prostate tissue; by microwave thermotherapy).

Ace When Modifier 52 Applies

Some coders lean toward modifier 52 (Reduced services) for discontinued procedures, since they reason that the urologist performed some of the procedure, albeit a reduced portion of it. However, this modifier isn’t meant for halted procedures. Instead, it allows you to tell a payer that your urologist performed a procedure, but the procedure falls short of what’s described by the code.