Amy Posted Tue 18th of March, 2014 14:04:54 PM
Pt comes to the ASC for a colonoscopy. Pt is brought back into the center, hooked up to the ECG, and an IV is started. The patient is having shortness of breath, so the Dr comes to talk to the patient and it is decided to cancel the procedure due to the patient's respiratory status. The patient is never sedated, nor is the scope ever used.
One of our coders was instructed to bill 45378-53 for the pro-fee. I don't see how we can do this since the scope was never inserted. I queston whether we can bill anything for the professional services.
Also, The ASC modifier 73 states when discontinued prior to the administration of anesthesia, but is not to be used for the elective cancellation of a procedure. In the case I described above, is it appropriate to bill 45378-73 for the facility charge, or would this be considered an elective cancellation?
SuperCoder Answered Wed 19th of March, 2014 04:01:15 AM
You’re correct in saying that modifier 73 (Discontinued outpatient hospital/ambulatory surgery center [ASC] procedure prior to the administration of anesthesia) does not apply when the surgery is canceled because the patient decides (for whatever reason) to not go through with the procedure. Explanatory notes in CPT® state that modifier 73 applies when the surgeon cancels the procedure prior to anesthesia administration because of extenuating circumstances or because the patient’s wellbeing might be threatened.
Additional guidelines state, "The elective cancellation of a service prior to the administration of anesthesia and/or surgical preparation of the patient should not be reported." You can, however, bill for any services that were provided to the patient up until that point, such as lab tests or X-rays.
Amy Posted Wed 19th of March, 2014 08:15:12 AM
Thanks for the reply.
What about the first portion of my question that pertains to the pro-fee? Is it appropriate to bill 45378-53 if the scope was never used and the patient was never sedated?
SuperCoder Answered Wed 19th of March, 2014 16:28:45 PM
Use modifier -53 with a reduced charge. However, according to CPT 2001, this modifier is more suited to operating room cases that are discontinued due to circumstances that threaten the well being of the patient. But modifier -53 is not limited to the operating room. The confusion comes from the misinterpretation of a note in the CPT definition that says, This modifier is not used to report the elective cancellation of a procedure prior to the patients anesthesia induction and/or surgical preparation in the operating suite. An operating suite does not have to be an operating room, experts contend.
Sometimes billing for a failed procedure can be a political issue. Many physicians do not bill for an unsuccessful procedure and will not code a painful procedure that was unsuccessful.
However, this can cause problems because the official coding guideline for the facility is to code the procedure even if the desired result was not achieved. The reasoning for this is to ensure that the supplies, time and the attempt were documented. Therefore, if the doctor does not code, facility procedure codes may not match the professional fee coding. Strictly from a coding point of view, the rule of common sense would apply to these scenarios. If a majority of the major steps of the procedure were performed and documented, then using a reduced charge seems appropriate. If very little was done, then not charging seems correct.