Janet Posted Thu 13th of February, 2020 12:54:54 PM
The provider stated " I then attempted ethmoidectomy. I infractured the right ethmoid bulla and the patient reported he was in too much pain to continue. He had adequate anesthesia but was too anxious to proceed. In this case could the ethmoidectomy be coded ?
SuperCoder Answered Fri 14th of February, 2020 00:43:27 AM
Thank you for your question.
You can report the ethmoidectomy procedure, since part of the procedure was initiated (infractured the right ethmoid bulla). Append modifier-53 to the procedure code to indicate that the procedure was discontinued due to patient’s health condition (i.e. pain and anxiousness)
According to CPT®; append modifier 53 (Discontinued procedure), if the provider elects to terminate a surgical or diagnostic procedure due to extenuating circumstances or those that threaten the wellbeing of the patient. The Payment for discontinued procedures is based on percentage of service completed.
Hope that helps!