Heidi Posted Thu 26th of July, 2018 17:01:52 PM
Patient came in to have an MRI of the Abdomen without contrast (CPT code 74181); during the MRI, Only axial SS fast spin echo localizer images were obtained. Patient had heating in her neck during the scan, therefore, the examination was terminated by the MR technologist. Patient has a history of prior cervical fusion in 2005 with titanium plate and screws.; can this be billed as a complete MRI or do we need to bill this as an incomplete MRI with modifier 53 attached?
SuperCoder Answered Fri 27th of July, 2018 02:29:43 AM
Depending upon the exact circumstances, modifiers -52 or -53 may be appropriate.
Modifier -52 (reduced services) states, under certain circumstances a service or procedure is partially reduced or eliminated at the physicians discretion. This is usually for services that were started (eg, all the prep work was performed and the test partially completed) but stopped because a patient left against medical advice.
Modifier -53 (discontinued procedure) may also be considered based on the documented details. The definition states, under certain circumstances, the physician 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.
The scenario you describe is discontinued due to patient had heating in her neck during the scan. The physician deemed this as affecting the patient’s well-being and stopped the procedure for that reason, it would be more appropriate to use the -53.