The office visit is the main procedure being billed as the physician documented a full o.v. note with all 3 elements in detail and also is utilizing the endometrium CA diag as this patient is a new patient. The physician then began the procedure and aborted due to a complication with dilation. Hope that makes more sense..
My confusion is with the 53 modifier. It states in the CPT book that it is not used to report the elective cancellation of a procedure prior to the patients anesthesia induction and/or surgical preparation in the operating suite. Does that mean that if a patient is not receiving anesthesia, then this modifier cannot be used. Because that description is confusing. Elective may be the key word here, but I am not sure. This patient was having the procedure done in the office w/o anesthesia. Can this modifier be used due to those circumstances? And if you have had any circumstances like that in your OBGYN office, how would you bill that? Thank you, sorry for the confusion.