Radiology Coding Alert

Questions:  Our radiologist performed a modified barium swallow study with videoradiography. The patient became ill during the procedure and the radiologist decided to cut the procedure short. The patient has a diagnosis of esophageal reflux. How should we code this?


Arkansas Subscriber


Answer: Good eye - noticing that the radiologist didn't finish the procedure is very important because you need to append modifier 53 (Discontinued procedure) to the code for the study (74230, Swallowing function, with cineradiography/videoradiography) to indicate that the physician didn't finish the procedure.

ICD-9 decision: Report the diagnosis with code 530.81 (Esophageal reflux). Because the physician chose to cut the procedure short, your payer may ask you to report one of the following V codes, depending on the cause of the discontinuation:
  ICD-9 V64.1 - Surgical or other procedure not carried out because of contraindication
  ICD-9 V64.2 - ... because of patient's decision
  V64.3 - Procedure not carried out for other reasons. Modifier 53 essentials: According to the CPT manual, you should reserve modifier 53 for situations when the physician chooses to terminate a procedure because of extenuating circumstances, including those that threaten the well-being of the patient. You shouldn't use 53 when the patient or physician cancels the procedure before anesthesia or surgical prep.

Alternative: Instead of appending 53 to the discontinued procedure, you may code for a completed portion of the procedure that has its own CPT code.

If necessary - based on the site of service and your compliance program - obtain a revised request from the referring physician to support the coded examination.