Wiki Discontinued Procedure

[JRalston]

My physician was in the beginning stages of performing a lumbar arthrodesis when the patient lost all vitals, causing the surgery to be aborted. The doctor is wanting me to bill the entire procedure with the -53 modifier, however, since he only was able to make the incision and had barely begun to separate the paraspinal muscles from the vertebral column when the complications began, I am thinking that I should only bill the primary procedure code with the -53 modifier. Am I right on this? I have spoken to other coders in our community and the response was mixed.

 

[JEMiller]

Modifier question

My understanding is you should code to the highest level completed. Was this done as an inpatient? If so I would agree with your doctor and submit the CPT code for that procedure with the modifier 53 and if it was an outpatient or SDC procedure then I would use modifier 74.

This provides a way to report the procedure intended.

Joan Miller, CPC

 

[JRalston]

Thanks, Joan. That was my thought as well, but my physician is wanting me to bill the entire list of intraoperative procedures (instrumentation, etc.) with the -53 modifer even though he only barely got past the incision before the patient began having problems. This was an inpatient procedure so the -53 is the correct modifier on this. Thanks again!

 

[penguins11]

My understanding to code only the primary procedure with the 53 in this situation not the whole list of codes and also being he didn't get very far, if the insurance company asks for the OR, they may significantly reduce the code. I would go with 22612, 22630 or 22633 and the 53 modifier depending on which procedure he was intending to perform.

 

[lindaconway]

I'm way late to this thread but would like to express my thanks for the helpful information!