You often turn to modifier 53 (discontinued procedure) when your anesthesiologist or the surgeon sees some risk that could threaten the patient’s health if the procedure continues. However, Payers do recoil when it comes to reimbursing these claims. Here are three easy steps by the experts to help you to get on the right track for reimbursement.
1) Conquer Electronic Filing Challenges
Gone are the days when you were told to submit paper claims reporting modifier 53 so you can append a written explanation with the claim. With HIPAA and electronic standards, you can do the billing electronically. Once you have billed electronically with modifier 53, the payer might request more information. Thus the note should contain all the information the carrier needs. For failed procedure, the record should state the reasons for the failure. If your physician discontinued the procedure due to the patient’s condition, the record should detail what factors prevented the procedure from going forward.
2) Verify the Timing of Cancellation
Knowing exactly when the case was canceled in terms of the physician’s work will help guide your code choices. If the physician cancels the procedure after induction, the case technically became a surgical procedure. Determine the correct surgical code, such as 45380 for a colonoscopy with biopsy. Then cross to the correct anesthesia code, such as 00810. If the cancelled procedure took place in an outpatient hospital or ambulatory surgical center, some payers require modifier 73 or modifier 74. In those situations, append modifier 73 or 74 to the anesthesia code instead of modifier 53 as modifiers 73 and 74 are specifically for outpatient hospital use.
3) Include the Correct Diagnosis
Indicate the reason for cancellation by reporting the appropriate diagnosis code or codes. For a patient who experiences syncope while still in the pre-op area before her procedure diagnosis codes such as V64.1 and 780.2 should be used on the claim. You may also report the diagnosis for the scheduled procedure, which would depend on when the physician canceled the case.
