Discontinued Heart Cath

mtrandel

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Our physician had a patient present for a left heart cath but the procedure was discontinued as follows:

INDICATION AND DESCRIPTION OF PROCEDURE: Right groin and right wrist were prepped and draped
in the usual sterile fashion. Lidocaine 1% was administered on the right wrist and right groin for
the anesthesia. Using fluoroscopy and ultrasound guidance, a microsheath was placed, a microneedle
was advanced into the right common femoral artery. She was noted to constantly moving both lower
extremities. She was sedated with 1 mg of Versed and 25 mcg of fentanyl for conscious sedation by
the RN in the room. She was continuously monitored with pulse oximetry, blood pressure, heart rate,
oxygen saturation, telemetry, direct observation by myself and by the RN. Because of her constant
leg movements, it looks like restless leg syndrome while she was sedated, we decided not to proceed
further. It was felt to reschedule with the help of anesthesiology. The needle was removed from the groin.
Manual pressure was held. She remained hemodynamically and clinically stable. She was transferred to Day Surgery.
The total sedation duration was 15 minutes.

How would this be coded? I know 99152 for the conscious sedation but am unsure of the rest. Thanks in advance!
 

SharonCollachi

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Clovis, CA
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Use the regular procedure code you normally would use, and modifier 53.


Modifier 53 — Discontinued Procedure Add this modifier to a surgical or diagnostic procedure code when the physician elects to terminate the procedure due to the patient’s well-being.

  • Do not use this modifier to report the elective cancellation of a procedure prior to the patient’s anesthesia induction and/or surgical preparation in the operating suite.
  • Do not use it on a time-based code.
  • When using modifier 53 to report a surgical procedure, you must submit an operative report. Operative notes must document why and at what point the procedure was discontinued. If the procedure is not surgical, a statement or report of how the procedure performed differed from the usual must be submitted with the claim. Reduce the normal fee by the percentage of the service you did not provide.

Modifier 53 examples:


  • Discontinued colonoscopy, for example due to poor preparation or tortuous colon.
  • After the surgical procedure was initiated and prior to completion, the patient’svital signs diminished to a point where the physician aborted the procedure.
 
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