General Surgery Coding Alert

Question: A patient was intubated, and general anesthesia was established. But despite efforts over the next 30-40 minutes, the surgeon did not feel that the patient could be ventilated adequately. The surgery was canceled. The patient was not prepped, and no incision was made. How should we bill this?

Tennessee Subscriber  

Answer: Most Medicare and some private insurers will not recognize a reduced-service modifier or offer any payment unless the patient has been prepped and an incision started. Check with your individual carrier regarding its policy for canceled surgeries. For carriers that do not have this policy, the surgeon should bill the appropriate procedure code with modifier -53 (Discontinued procedure) for a possible reduced fee.
 
According to the CPT descriptor for modifier -53, 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, you may need to indicate that the surgeon started a surgical or diagnostic procedure but had to discontinue it.
 
At best, with proper documentation you may be able to report an established outpatient E/M or subsequent inpatient E/M service (for example, 99232) along with a diagnosis of V64.1 (Surgical or other procedure not carried out because of contraindication) to indicate that the physician called off the procedure.

Note: Modifier -53 is not appropriate to report the elective cancellation of a procedure prior to the patients anesthesia induction and/or surgical preparation in the operating suite.