Camille Posted Mon 21st of October, 2019 15:39:14 PM
If a surgeon performs 30465 (which includes bilateral procedure) only on the pt's. right sided nasal stenosis, is it necessary for the ASC to use a modifier -52 (30465-SG-52-RT) and take a 50% pmt. reduction? Or is the ASC allowed to bill (30465-SG-RT) and expect the full allowed amount? Per CMS, as of 01/01/2008 Modifier -52 is intended for use to indicate discontinuance of radiology procedures and other procedures that do not require anesthesia. I do not find an appropriate ASC modifier for a planned procedure reduction requiring anesthesiology. I note that codes billed with modifier -74 are paid at 100% of allowable in the ASC. Is it safe for me to assume i do not have to code a right-sided 30465 with any modifier other than (SG and) -RT for ASC coding? Thank you very much!
SuperCoder Answered Tue 22nd of October, 2019 03:23:12 AM
In ASC setting, procedures that are discontinued, partially reduced or cancelled after the procedure has been initiated and/or the patient has received anesthesia will be paid at the full OPPS payment amount. Modifier -74 is used for these procedures.
Procedures for which anesthesia is not planned that are discontinued, partially reduced or cancelled after the patient is prepared and taken to the room where the procedure is to be performed will be paid at 50 percent of the full OPPS payment amount. Modifier -52 is used for these procedures.
Use appropriate modifier as per your scenario for reduced services.
Camille Posted Fri 22nd of November, 2019 16:21:34 PM
Hi SuperCoder! I am just now having a chance to review your answer. If my reply question is too late, I will gladly ask a new question, but please refer back to this thread. The phrasing is a little ambiguous: "procedures that are discontinued, partially reduced or cancelled after the patient is prepared and taken to the room where the procedure..." Specifically, is it meant that the decision to partially reduce must be made after the anesthesia-what if it was preplanned to perform half of the procedure. Based on the scenario I described (above), which ASC modifier is applicable? 52, 73, 74? 30465-? Thank you, kindly!
SuperCoder Answered Tue 26th of November, 2019 07:29:28 AM
Hope you are keeping well.
According to the AMA guidelines, if the surgeon performs 30465 (which is a bilateral procedure) only on the one side (Right or Left), then use modifier 52 (Reduced Services). Payment will be decided by the payer according to the modifier appended.
However, modifier 73 and 74 are for the discontinued procedure prior and after administration of anesthesia, respectively, in the Out-Patient Hospital/Ambulatory Surgery Center (ASC) place of service.
In your scenario, since it was decided to perform the procedure on one side only (right), according to the general coding guidelines, it is appropriate to bill the 30465-RT,SG,52 when billing for Ambulatory surgical center (ASC) facility service.
Hope this helps!