Discontinued Procedure

martnel

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How would y'all code this? This was done in an ASC.

I did: 26115-74 and 20612 and the insurance approved and paid, but the patient had a huge deductable and do not want to pay us. I just wanted to make sure that I understand this discontinued modifiers correct?

ANESTHESIA: General

NAME OF OPERATION: 1. Excision of mass, procedure aborted.
2. Aspiration of mass, right hand

INDICATIONS: This child has a history of an enlarging mass about the volar aspect of the right hand and is now here for the above-listed operative procedure.

PROCEDURE: The patient was taken to the operating room. Numerous attempts were made to start an intravenous line for the procedure.

The operative procedure was aborted, after anesthesia was administered. However, an 18 gauge needle was used to attempt to aspirate the lesion and this was noted to be a cystic mass which was decompressed.
 

martnel

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Is there any documentation for this? None of the info that I have says what to do if a replacement (not scheduled) procedure was done. I appreciate all your input!
 

mitchellde

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Go back to the federal register where the 53 modifier is discussed. I read this several years back... also I think I recall a CPT assistant on this as well. I read this as I said many years back, I follow every rule and rule change very carefully and there has been nothing new that I have read on this so I have to assume everything I read all those years back is still current and accepted. When I say years back I am going back to around 1998 or so.
 

martnel

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Thanks Mitchellde! I have read that, but I am still not 100% on this one. I also looked into the payment, because I was trying to figure out why I did it this way. I found out that the second or replacement procedure is not covered by the insurance in an ASC. Should I still only bill for that (20612), and get nothing, or should I bill ONLY for the first (aborted, scheduled) procedure? If they planned to do a aspiration, they would have done that in the office. I want to do what is right, not what is most money. I also feel like if we cannot bill 26615-74, the patient should not get the benefit of a deductable being taken care of, and I should then probably do a corrected billing?
 

mitchellde

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I know you feel kind of backed into a corner on this, however I would bill the procedure acomplished, the aspiration.
 

mbort

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Since you are in an ASC, yes you can bill for both the aborted procedure and the completed procedure. You did do it correctly. Anesthesia was performed for the major procedure which was aborted. Also the note that you posted does not state that the aspiration was complete...it was attempted. I would do the primary planned procedure with the 74 modifier and not code for the aspiration because it only states attempted.

my two cents
Mary, CPC, COSC
 

mitchellde

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I got the impression the aspiration was performed, if not accomplished then go for the discontinued as Mary states. Sometimes when going thru these threads you can lose track of the original statement. So was the aspiration completed? BUt you may not bill for both the completed and the acomplished procedure at the same time either ASC or hospital outpatient, unless this is a new ruling within the last year or so.
 

martnel

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The aspiration was completed, I know this by talking to the doctors involved. The note also stated that it was decompressed - is that the same thing as aspiration?

My problem with the second procedure is that it was not scheduled, and it is not a covered procedure for this insurance for ASC. They would not have done this here, if they knew upfront. Was this not incidental?
 

mbort

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I've been trying to locate something that states that you can only report one or the other and not both as Deb had indicated, but I come up empty handed. Its the first time I had ever heard it.

Deb, can you post your resource on this? I know you mentioned the Federal Register but I couldn't find anything that stated this in the Federal Register.

I have lots of stuff from CMS that just states the guidelines for reporting with the -74 modifier as well as many other resources which state the same, but none of them state that you can not bill a performed procedure with a terminated procedure.

I have a couple of ASC books at home that I will check as well to see if they have anything in them.

In your case Martn, I think you billed correctly (unless we can find the resource that states not too).

Because the resources of the facility are consumed in essentially the same manner to the same extent as they would have been had the procedure been completed. If this modifier is not used and the patient has to come back for the same procedure, then the subsequent procedure will be denied. If you were to choose not to bill it, I would still put it in your system as a "zero" charge for documentation/audit purposes.

As far as the aspiration goes, I would make sure that all the info you have obtained from your doc verbally is documented.

Mary, CPC, COSC
 

mitchellde

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Mary,
I read this several years ago when I was studing for APCs in the outpatient setting and I was reading everything I could get my hands on. This was in the federal register that I read this about the 53, 73, and 74. ANd as I said there may have been a CPT assistant on the same subject. I do not have these references any longer, they were archived on my laptop about 5 laptops ago! I wil see if I can reproduce the search and find it again.
 

RebeccaWoodward*

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http://www.cms.hhs.gov/Transmittals/downloads/R442CP.pdf

Termination Where Multiple Procedures Planned

When one or more of the procedures planned is completed, the completed procedures are reported as usual.

When one or more of the procedures planned is completed, the completed procedures are reported as usual. The other(s) that were planned, and not started, are not reported. When none of the procedures that were planned are completed, and the patient has been prepared and taken to the procedure room, the first procedure that was planned, but not completed is reported with modifier -73. If the first procedure has been started (scope inserted, intubation started, incision made, etc.) and/or the patient has received anesthesia, modifier -74 is used. The other procedures are not reported.

If the first procedure is terminated prior to the induction of anesthesia and before the patient is wheeled into the procedure room, the procedure should not be reported. The patient has to be taken to the room where the procedure is to be performed in order to
report modifier -73 or -74.
 

martnel

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I appreciate ALL your input and helping me on this. I am sure we all are learning here?

Rebecca, I already looked at that pages, and I just want to make it clear that the aspiration (20612, second procedure)was not PLANNED, according to me it was more incidental than anything else. Incidental you do not need to code, right?
 

mbort

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http://www.cms.hhs.gov/Transmittals/downloads/R442CP.pdf

Termination Where Multiple Procedures Planned

When one or more of the procedures planned is completed, the completed procedures are reported as usual.

When one or more of the procedures planned is completed, the completed procedures are reported as usual. The other(s) that were planned, and not started, are not reported. When none of the procedures that were planned are completed, and the patient has been prepared and taken to the procedure room, the first procedure that was planned, but not completed is reported with modifier -73. If the first procedure has been started (scope inserted, intubation started, incision made, etc.) and/or the patient has received anesthesia, modifier -74 is used. The other procedures are not reported.

If the first procedure is terminated prior to the induction of anesthesia and before the patient is wheeled into the procedure room, the procedure should not be reported. The patient has to be taken to the room where the procedure is to be performed in order to
report modifier -73 or -74.
Rebecca...you are awesome!!!! Thank you so much for taking the time to dig this up for me :)
 
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