Wiki 99211 for cancelled facet joint injection

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melbarbee

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A provider is performing facet joint injections and other spinal injections in the physician's office. In one instance, the physician cancelled a lumbar facet joint injection because the patient's blood sugar was high and the procedure was to be rescheduled.

The provider billed a 99211 to Medicare for this service, rather than using the code for the procedure and appending a modifier.

I thought I had read some Medicare guidance that this would not be appropriate use of the code 99211 in this scenario, but have not been able to locate it.

Does anyone have any advice on this? Is there a difference in this case because it is a physician's office rather than an ASC?
Thanks for your help!
M. Barbee
 
One of the books I own from Ingenix, "Understanding Modifiers" states that to use modifier 53 the procedure must have been actually started, but was discontinued before completion due to the patient's condition (and does apply to the physicians office) Based on your example, not sure if this modifier would be appropriate. It also states to use the modifier if surgery is discontinued to situations that threaten the well-being of the patient, begging the answer to your question....And the carrier will want to see the medical notes, so, was the surgery actually started?

Not much help, I suppose, but am interested in an alternative choice if there be one!?!
 
The procedure needs to be started (anesthesia administration) in order to discontinue a procedure. Payment for discontinued procedures is based on percentage of service completed.
If the physician had a face to face with the patient then nothing less then a 99212 should be billed. Select the appropriate EM level of service based on the supporting documentation. 99211 do not require a face to face with the patient.

Keep in mind when you use Modifier 53 you must submit the documentation, you are reimbursed based on how much of the procedure was performed.

WPS does have a fact sheet on this.
Novitas
Note: This modifier is not used to report the elective cancellation of a procedure prior to the patient?s anesthesia induction and/or surgical preparation in the operating suite. For outpatient hospital/ambulatory surgery center (ASC) reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for ASC hospital outpatient use)

Check with you Medicare Administrator Contractor, they may have some form of fact sheet.

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R442CP.pdf
 
I was going with the indication that there was more than the lumbar facet injections, there was other things that could have been done.
 
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