Use Modifier -53 for Partial Reimbursement of Discontinued Procedures- Published on Sun, Apr 01, 2001
A discontinued or failed procedure is one that stops before completion, usually because the patients health is or would be at serious risk if the procedure were to continue. Yet some ob/gyn physicians and coders have misconceptions about how to code the surgery and which modifier to append when a procedure is discontinued. Further, the difference between a discontinued procedure and a failed procedure that is converted to another procedure is significant when it comes to proper coding and reimbursement. Getting it wrong could cost your practice legitimate revenue, or cause you to stray into fraudulent coding.
A discontinued or terminated procedure is one that is stopped before completion. That means that surgery was stopped, the incision was closed and the patient was removed from anesthesia and taken to recovery. Causes may range from the patients excessive hemorrhaging, negative reaction to anesthesia, or the surgeon discovering a condition once surgery has begun that precludes him or her from completing the surgery. A surgery is most often discontinued when the patients well-being is at risk and continuing the surgery threatens that well-being. In such cases, modifier -53 (discontinued procedure) is appended to the procedure code.
If a procedure is attempted, and the surgeon discovers he or she must switch to a different procedure because of findings or the patients anatomy, the first procedure is considered neither failed nor discontinued it is converted.
The difference between discontinued and converted is crucial to correct coding. The use of modifier -53 depends on why the physician could not complete the procedure, as well as what else he or she actually did afterwards, says Susan Callaway, CPC, CCS-P, a North Augusta, S.C.-based independent coding consultant and educator. If the ob/gyn stopped the procedure because it was endangering the welfare of the patient, append modifier -53. But if upon starting the initial surgery, he or she converted to another procedure, the surgeon can bill only for the second one. The first procedure is not a billable item, except under very specific circumstances (see coding examples below).
Questions about coding for discontinued procedures often come up when a procedure has been converted. Tracey Maille, a surgical coder for Ashtabula Clinic in Ashtabula, Ohio, offers the following example: The patient had pelvic pain with a history of endometriosis, Maille explains. The laparoscopy (58660, laparoscopy, surgical; with lysis of adhesions [salpingolysis, ovariolysis] [separate procedure]) was begun, the pelvis was visualized, and significant adhesions were discovered. It was evident that the amount of scarring posterior to the ovary and tube was significant enough for the surgeon to convert to an open procedure in order to remove the tube and ovary (58720, salpingo-oophorectomy, complete or partial, unilateral or bilateral [separate procedure]). [...]