Wiki Discontinued/reduced I&D - modifier needed?

[ca_cpc]

Hi all - I'm trying to figure out the best way to bill the below procedure. Basically, our provider started an abscess I&D and then stopped because "mass was not able to be drained." I'm guessing this should be a 10060 with a -52 "Reduced services" modifier, but I would really appreciate a second opinion. Would a -53 be more appropriate? Something else entirely? I'm in primary care and haven't seen this before!
Thank you!
Christie Anna

Procedure:
- Area examined. Firm, 3 cm diameter slightly mobile mass in left axilla. There is no overlying redness, no poor and no drainage.
- Informed consent obtained
- Sight marked and cleared use Betadine.
- 3 cc of 2% Lidocaine w Epi injected with good superficial anesthesia achieved.
- Using an 11 blade a 1 cm incision was made
- No pus was expressed. Only blood present. Wound probed with sterile Q-tip
- Procedure was stopped as mass was not able to be drained.
- Area was cleaned and bandaged.
- Pt given 1000 mg Tylenol in Office ( had taken 800 mg Ibuprofen 1 hour prior). Given Wound care instructions.

 

[Chelle-Lynn]

I would use modifier 53 as the procedure was discontinued; Procedure was stopped as mass was not able to be drained. It meets the definition of 53 as you are

reporting a procedure/service that was cancelled as a result of extenuating circumstances. The area could not be drained as the mass was larger than expected. So it does not appear to be reduced.​