Question Attempted C-section delivery- Modifier 53 or 52?

[hema_anan]

We are a physician group practice and our Obgyn provided antepartum, postpartum services and performed an attempted C-section but wasn't able to deliver the baby due to extenuating circumstance. We think our MD should be rightfully paid for the reduced global service. We billed as 59510 with modifier 53 (since surgery terminated after anesthesia administered) along with dx codes O43.893, O34.211, K56.50.

Medicaid has denied this claim due to inappropriate modifier. Modifier 52 is for surgery reduced prior to anesthesia administration and we don't think this is appropriate.

Extenuating circumstance: Anesthesia was administered, surgery had begun but had to be stopped due to extensive adhesions, suspicious uterus lesion encountered with high probability of abnormal placentation, there was limited staff and hospital resource to safely deliver baby. Patient was made sure to be hemodynamically stable, sutured up and transferred to another hospital.

Anyone with similar situation? How would you bill for this?
Appreciate any insight, thoughts and any reliable resources(CPT, ACOG etc.) you have found to be helpful.

 

[nielynco]

We are a physician group practice and our Obgyn provided antepartum, postpartum services and performed an attempted C-section but wasn't able to deliver the baby due to extenuating circumstance. We think our MD should be rightfully paid for the reduced global service. We billed as 59510 with modifier 53 (since surgery terminated after anesthesia administered) along with dx codes O43.893, O34.211, K56.50.

Medicaid has denied this claim due to inappropriate modifier. Modifier 52 is for surgery reduced prior to anesthesia administration and we don't think this is appropriate.

Extenuating circumstance: Anesthesia was administered, surgery had begun but had to be stopped due to extensive adhesions, suspicious uterus lesion encountered with high probability of abnormal placentation, there was limited staff and hospital resource to safely deliver baby. Patient was made sure to be hemodynamically stable, sutured up and transferred to another hospital.

Anyone with similar situation? How would you bill for this?
Appreciate any insight, thoughts and any reliable resources(CPT, ACOG etc.) you have found to be helpful.

I would have to agree that modifier -53 would not be correct in this situation because you are trying to bill a global service, not just the delivery. You could have used -52 and let them know your provider did not do the delivery, but only if you also intend to provide all the PP care as well. A better option would be to bill antepartum and PP services separately and bill for a exploratory laparotomy for the surgery that was done. The new hospital providers will be billing for the delivery and probably also inpatient PP care so you might be providing on outpatient PP care in addition.

 

[hema_anan]

Thank you so much for sharing your expertise. Your reasoning for 52 makes sense and we tried but was denied again. Will try the separate billing.