Billing modifier -53

jrburke

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We have a physician that did an injection on a patient, patient was scheduled for Right L4/5 L5/S1 Transforaminal ESI, consent was signed, procedure began, under fluro injection could not be completed due to osseous obstruction at both levels, needles were withdrawn, patient was re-anesthetized, and a Right L4/5 Interlaminer ESI was attempted, but again aborted due osseous obstruction; needles were withdrawn, patient was again re-anesthetized,a Right L5/S1 Interlaminer ESI was then attempted but again aborted due osseous obstruction; needles were withdrawn, Since this was the 3rd attempt after discussion with patient decision was made to attempt a Caudal ESI this was successfully completed.

Our thoughts were to bill 64483/53RT, 64484/53RT and 62311. Please let me know if you would agree or if you would just bill for the 62311.

Thank you so much for your professional opinion's on this matter.
 

dwaldman

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If the procedure is discontinued you only report one code with the 53 modifier.

If a procedure is completed and some of the procedures that were consented for were not completed, you can only report the completed procedure.
 
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