Wiki aborted prostatectomy

[lbarbar]

Hello .....i have this patient who is here for radical prostatectomy (had a prostate cancer) ….. the surgeon did laparotomy …. then the prostate was attached to the rectum and inseparable from it.there was a right inguinal hernia , it was repaired …….the operation aborted due to inability to separate prostate from rectum.

I have three choices here for the code:
1. Radical prostatectomy with modifier 52
2. Radical prostatectomy with modifier 53
3. Exploratory laparotomy.

How do you think I should code this case?

I really do appreciate your help

Linda Barbar

 

[TammyHF]

I would use 52 modifier if billing commercial insurance to include copy of the operative note but for Medicare claims in box 19 you have to put "ADDITIONAL INFORMATION AVAILABLE UPON REQUEST" and send the op note when Medicare request it. The 53 modifier requires documentation of extenuating circumstances that threaten the well-being of the patient that required the procedure to be discontinued. Now if there documentation a life threatening event then use 53 modifier.