Avoid Denials by Using Modifiers -52, -73 and -74

When coding discontinued, reduced or canceled procedures, knowing when to use the appropriate modifier is important to avoid denials. Using modifier -52 (reduced services), -73 (discontinued out-patient hospital/ ambulatory surgery center [ASC] procedure prior to the administration of anesthesia), or -74 (discontinued out-patient hospital/ambulatory surgery center [ASC] procedure after administration of anesthesia) will depend on whether anesthesia was given before or after the procedure was started and whether anesthesia is an inherent part of performing the procedure. Also, the modifier descriptors are affected by which codes they are used with. For example, the modifier descriptors are different if they are used for surgery codes versus radiology codes.

Applying Modifier -73

You should use modifier -73 for an outpatient hospital procedure that is discontinued after the patient is prepped, but before anesthesia is given.

For example, a patient is being prepared for endoscopy (43235, upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]) and the procedure will be performed under general anesthesia.

When the anesthesiologist rechecks the patients blood pressure, the patient is grossly hypertensive and the procedure is canceled before the introduction of the general anesthesia. This scenario would be coded as 43235-73 with V64.1 (surgical or other procedure not carried out because of contraindication).

You should remember that you cannot append modifier -73 unless you report ICD-9 codes V64.1, V64.2 (surgical or other procedure not carried out because of patients decision) or V64.3 (procedure not carried out for other reasons) to support the reason for the modifier. If you use modifier -73, only half of the procedure may be paid because the procedure is incomplete, explains Caral Edelberg, CPC, CCS-P, president of Medical Management Resources Inc., an emergency medicine coding company based in Jacksonville, Fla.

The ICD-9 codes support the reason for the modifier and most carriers will have edits to kick out anything with a modifier -73 and no V64 ICD-9.

Using Modifier -74

Using the above example of endoscopy, you can also bill the procedure with modifier -74 even if it was halted, for example, because the patients blood pressure has suddenly started to climb after the anesthesia was administered. The procedure is coded 43235-74.

Note: As with modifier -73, you must also have an ICD-9 code of V64.1, V64.2 or V64.3 when appending modifier -74 to ensure payment.

If more than one procedure was planned, report only the procedures that were completed. If none of the procedures were completed, report only the first procedure planned.

When using these modifiers for radiology services, the modifiers should be used to show a radiology procedure that was canceled before it [...]

- Published on 2001-02-01