Wiki Unsuccessful Surgery Modifiers

[coderfromtexas]

Patient was scheduled for a revision total shoulder. Surgeon attempted to remove the stem from the humerus but was unsuccessful. Patient was closed back up and will be referred to a larger specialty facility. Patient was in surgery 2 hours. What modifier would be appropriate for an attempted but unsuccessful surgery? Thanks!

 

[CBLENNIE]

I would say that modifier 53 is most appropriate in this situation since the provider elected to discontinue the procedure as they were unsuccessful in removing the stem from the humerus. The description of modifier 53 states in part:

Under certain circumstances, the physician or other qualified health care professional may elect to terminate a surgical or diagnostic procedure. Due to extenuating circumstances or those that threaten the well being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued. This circumstance may be reported by adding modifier 53 to the code reported by the individual for the discontinued procedure. Note: This modifier is not used to report the elective cancellation of a procedure prior to the patient's anesthesia induction and/or surgical preparation in the operating suite.​

If you are billing for an outpatient hospital or ASC, see modifiers 73 & 74.