Cardiology Coding Alert

Question: Can we bill an unsuccessful procedure? The operative reports reads,Angioplasty of both the renal arteries was attempted utilizing multiple catheters, guides and wires to cross the lesions. Angioplasty was unsuccessful because of inability to cross the lesions. No complications were experienced. Failed intervention of both renal arteries due to inability to cross the angulated, calcified renal artery lesions. Recommend bypass surgery to the renal arteries.

Oregon Subscriber

Answer: When a procedure is cut short without an end result, the appropriate CPT code should be billed with modifier -53 (discontinued procedure) appended, says Kathleen Mueller, RN, CPC, CCS-P, an independent coding and reimbursement specialist in Lenzburg, Ill. In this case, the session should be billed 35450-53 (transluminal balloon angioplasty, open; renal or other visceral artery, discontinued procedure).

Modifier -53 tells the carrier that the procedure was attempted but not completed. This differentiates it from modifier -52 (reduced services), which describes a procedure that was completed but was less extensive than described in the CPT code, Mueller says.