Urology Coding Alert

Question: A patient scheduled for an outpatient cystoscopic procedure was in the outpatient surgery suite under sedation. But before the urologist started the procedure, the patient changed his mind about the procedure, and the physician discharged him. Would it be appropriate to code this cancelled procedure with modifier 73?


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Answer: No, modifier 73 (Discontinued outpatient hospital/ambulatory surgery center [ASC] procedure prior to the administration of anesthesia) wouldn't be appropriate in this case.

According to CPT, modifier 73 requires the physician's decision to cancel the procedure "due to extenuating circumstances or those that may threaten the well-being of the patient."

In this situation, the patient himself made the choice to stop the procedure, so you shouldn't report the intended procedure code at all.

Modifier 73 is only approved for use by the ambulatory surgery center (ASC) or hospital outpatient units. Appending modifier 73 to a procedure code indicates that the procedure took place in an outpatient or ambulatory surgery center prior to anesthesia (which CPT defines as general anesthesia), but this patient was sedated.

Tip: Don't be tempted to use either modifier 52 (Reduced services) or modifier 53 (Discontinued procedure), because no part of any procedural service was performed, and there was no physician discretion in this decision.

Best bet: Report an E/M code based on the documentation provided, and add the injections given for the sedation. Answers to Reader Questions and You Be the Coder contributed by Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology, State University of New York, Stony Brook; and Morgan Hause, CCS, CCS-P, privacy and compliance officer for Urology of Indiana LLC, a 31-urologist practice in Indianapolis.