Neurosurgery Coding Alert

Question: A neurosurgery patient was intubated, and general anesthesia was established. The patient was turned prone onto the spinal table and had increase peak pressures greater than 20. Despite efforts over the next 30 to 40 minutes, the neurosurgeon 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?

Tennessee Subscriber

Answer: Most Medicare and some insurance carriers consider that unless the patient has been prepped and an incision started, the use of any reduced-services modifiers may not be recognized and no reimbursement offered. Check with your individual carrier regarding their policy for canceled surgeries. For carriers who do not have this policy, the neurosurgeon should bill the procedure code with modifier -53 (discontinued procedure) for a possible reduced fee.

According to the CPT 2001 description 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, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued.

Note: 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.