Wiki Mod 53 -perform a hip replacement

[skorkfranks]

Had a doc who was going to perform a hip replacement. The anesthesiologist administered a regional spinal and after placement of the spinal, the patient began to defecate uncontrollably for about 15 minutes. Once this subsided, the patient was cleaned and then turned in the left lateral decubitus position to move forward with the hip replacement. The patient then began significant vomiting and it was at that time that Anesthesia cancelled the surgery.

Should this be billed as 27130-53? This was inpatient surgery not performed at an ASC. Thanks.

 

[mitchellde]

Yes if billing for the surgeon use the code for the procedure plus the 53 modifier also as a secondary dx code use a code from the V64 category.

 

[FTessaBartels]

Was surgery even started?

I'm not sure about this ... doesn't seem to me that the patient was even draped yet, let alone that surgery had begun.

I'd be inclined to have the surgeon document his E/M service for this and that's all I would code.

F Tessa Bartels, CPC, CEMC

 

[mitchellde]

The parameters for the 53 modifier are met if the patient is in the room where the procedure is to be performed. I guess you could do either but I vote for the procedure code with the 53 modifier.

 

[mbort]

I'm not sure about this ... doesn't seem to me that the patient was even draped yet, let alone that surgery had begun.

I'd be inclined to have the surgeon document his E/M service for this and that's all I would code.

F Tessa Bartels, CPC, CEMC

Deb is absolutely correct. Once the patient enters the operating room, the facility and physician are entitled to be reimbursed for time and resources used.

Mary,CPC, COSC