Proper Use of Modifiers Increases Payment for Discontinued Procedures
Published on Wed Aug 01, 2001
When an ophthalmologist begins a surgical procedure but can't complete it, coders should know when to append modifier -53, -22 or -78 for fair and optimal reimbursement.
Modifier -53: Determine How Much of the Procedure Was Completed
Modifier -53 (discontinued procedure) for discontinued surgery tells the payer that the physician did not complete the procedure. Although the ophthalmologist's fee will be reduced accordingly, there is no prescribed reduction amount. The physician needs to determine how much of the procedure he or she completed, as well as how much follow-up will be necessary, and bill accordingly.
For example, a patient is prepped and draped for phacofragmentation cataract surgery with IOL insertion. The anesthesiologist starts monitored anesthesia care (sedation). The surgeon performs a retrobulbar block. The surgeon makes the incision and starts removing the cataract, but the patient starts moving on the table. At this point the anesthesiologist usually delivers more medication intravenously, but it may not be effective. "The surgeon determines that he or she needs to stop and close up," says Lise Roberts, vice president of Health Care Compliance Strategies, a Jericho, N.Y.-based company that develops interactive compliance training courses.
"The surgeon will usually opt for general anesthesia during the next try," Roberts says. This surgery would be coded 66850 (removal of lens material; phacofragmentation technique [mechanical or ultrasonic] [e.g., phacoemulsification], with aspiration) with modifier -53 appended.
For a minor procedure, consider the patient who cannot tolerate punctal plugs. The patient has excessively dry eyes, and the doctor plans to place punctal plugs in the lower puncta initially. But when the patient starts yelping -- even if the doctor is using a local anesthetic -- and is unable to sit still, the doctor has to stop.
"A lot of ophthalmologists might say, 'Let's just bill for an office visit,'" Roberts says. "But you should bill this as a discontinued punctal-plug insertion because of the supply." Medicare and other payers cover permanent plugs, but not temporary plugs, as a supply. In this case, the plugs would probably be collagen. The sterile package usually contains two plugs and would cost the practice at least $60 even though the physician couldn't insert them.
Bill for the procedure with 68761 (closure of the lacrimal punctum; by plug), with the appropriate eyelid modifier and modifier -53 appended. For example, if you attempt to place a plug in the upper left eyelid, bill 68761-53-E1. Always use modifier -53 before the eyelid modifier because payment modifiers always go in the primary position following the code, with the information modifier in the secondary position.
Sometimes a patient needs more than one plug. Perhaps you were able to implant one plug, but when you got to the second, you had to stop. For [...]
