Decode This Discontinued Prostate Procedure
Question: The patient was prepped for surgery and put under general anesthesia, after which the urologist began performing a transurethral resection of the prostate gland (TURP). The patient’s heart rate fell to 37 beats per minute, and the anesthesiologist was unable to raise it to a safe level. The team decided it was safest to discontinue the procedure before the urologist was able to address the affected portion of the prostate. The resectoscope was removed and the patient was taken to recovery. How should this be coded? Minnesota Subscriber Answer: For this situation, you’ll report 52601 (Transurethral electrosurgical resection of prostate, including control of postoperative bleeding, complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included)) and also be sure to append modifier 53 (Discontinued procedure) to reflect that the procedure was discontinued. You should make sure to submit the urologist’s documentation with the claim, and include ICD-10-CM diagnosis code R00.1 (Bradycardia, unspecified) to indicate the patient’s slow heartbeat. Make note: Depending on the place of service, appending modifier 74 (Discontinued out-patient hospital/ambulatory surgery center (ASC) procedure after administration of anesthesia) may also be appropriate. However, if the surgery did take place in an ASC, you would not also include modifier 53 on the claim. Lindsey Bush, BA, MA, CPC, Production Editor, AAPC 
