Article Date: 11/1/2006

CODING Q & A
Correct Coding for a Terminated Procedure

ANSWERS PROVIDED BY RIVA LEE ASBELL

Q. A patient was seen for PDT. The IV infusion of Visudyne was started. After 10 cc of infusion, the IV site became infiltrated and the infusion was discontinued. A dressing was applied. The risks and benefits of Macugen injection were explained and the patient agreed to that injection.

Can we bill Medicare for the Visudyne, Macugen, and injection? If so, how do we indicate the complication with the Visudyne so it can be paid? Modifier 53 would go on the laser, but it was not billed because it was not done. I do not think Medicare will pay Visudyne and Macugen on the same day without a modifier but I am unsure which would be appropriate.

A. Modifier 53 should be applied to the discontinued procedure, in this case CPT code 67221. The CPT definition of modifier 53 is: "Under certain circumstances, the physician may elect to terminate a surgical or diagnostic procedure. Due to extenuating circumstances or those that threaten the well being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued. This circumstance may be reported by adding the modifier 53 to the code reported by the physician for the discontinued procedure." Note: This modifier is not used to report the elective cancellation of a procedure prior to the patient's anesthesia induction and/or surgical preparation in the operating suite. For outpatient hospital/surgery center reporting of a scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or that threatens the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for surgery center/hospital outpatient use).

You should get paid for the 2 procedures (the PDT and the intravitreal injection), although there isn't a value assigned to modifier 53. Normally, if 2 procedures are performed at the same session they are paid under multiple surgery rules, 100% of the allowable of the first and 50% of the second etc. Both supplies should be paid since both were used.

Q. I understand that there is a significant difference in reimbursement for procedures performed in the global period of another procedure when modifier 58 is used. Could you give us some examples of when modifier 58 would be used in procedures considered staged? What is the difference between a staged procedure staged vs a procedure performed in different sessions?

A. The first use of modifier 58 is when coding a greater or more extensive procedure that follows a lesser or less extensive procedure in the global period. When this occurs in the 90-day global period, one must append the 58 modifier to obtain payment for the second procedure. Examples include a vitrectomy (67036) following a vitreous tap (67015), or repair of retinal detachment by scleral buckle (67107) or vitrectomy (67108) following pneumatic retinopexy.

A second use is for procedures performed in the global period that are staged (planned prospectively), such as removal of silicone oil (67121), and photocoagulation following injection of tissue plasminogen activator.

The third use is for therapeutic procedures that follow diagnostic procedures, again a vitreous tap followed by vitrectomy. The use of modifier 58 engenders Medicare payment at 100% of the allowable.

When the CPT definition has the phrase "one or more sessions," it signifies that as many sessions necessary to complete treatment are included in the reimbursement for that given procedure within the global period. You may need more than one sitting to complete the treatment but you may not bill more than once for the procedure. Just because you plan to do a panretinal photocoagulation, for example, in 2 or 3 stages does not mean that it is a "staged" procedure. A staged procedure is one that is planned prospectively to be done sequentially. Usually, there will be a different CPT code used.

The CPT is not consistent in its use of the terms "sessions" and "stages." If the descriptor includes the phrase "one or more sessions" or "one or more stages" then you do not bill extra for the continuation of the procedure, a different session of the procedure, in the global period.

CPT codes copyright 2005 American Medical Association.

Riva Lee Asbell is the principal in Riva Lee Asbell Associates, an ophthalmic reimbursement firm in Philadelphia. She can be reached through her Web site at www.RivaLeeAsbell.com.

 



Retinal Physician, Issue: November 2006