0157-Discontinued Procedure Prior to the Administration of Anesthesia: Coding and Documentation Requirements

Submitted by Matthew.Gregor… on Mon, 11/04/2019 - 07:47
Issue Number - Name
0157-Discontinued Procedure Prior to the Administration of Anesthesia: Coding and Documentation Requirements
Review Type
Complex
Date Approved
2019-06-04

Description

Modifiers provide a way for hospitals to report and be paid for expenses incurred in preparing a patient for surgery and scheduling a room for performing the procedure where the service is subsequently discontinued. This instruction is applicable to both outpatient hospital departments and to ambulatory surgical centers. Documentation will be reviewed to determine if the billed procedures meets Medicare coverage criteria and applicable coding guidelines for the use of modifier 73.

Affected Codes

Z53.01, Z53.09, Z53.1, Z53.20, Z53.21, Z53.29, Z53.8, Z53.9

Applicable Policy References

1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits
2. 42 CFR §414.40 Coding and Ancillary Policies
3. 42 CFR §419.44 Payment Reductions for Procedures
4. 42 CFR §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, Decisions, and Reviews, (b)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Initiated by a Contractor; and (c)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Requested by a Party
5. 42 CFR §405.986- Good Cause for Reopening 
6. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions,  §3.6.2.4- Coding Determinations
7. Medicare Claims Processing Manual, Chapter 4- Part B Hospital (Including Inpatient Hospital Part B and OPPS), §10.5- Discounting; §20.6- Use of Modifiers, §20.6.1- Where to Report Modifiers on the Hospital Part B Claim, and §20.6.4- Use of Modifiers for Discontinued Services
8. Medicare Claims Processing Manual, Chapter 14- Ambulatory Surgical Centers, §40.4- Payment for Terminated Procedures
9. Medicare Claims Processing Manual, Chapter 23- Fee Schedule Administration and Coding Requirements, §20.3- Use and Acceptance of HCPCS Codes and Modifiers
11. American Medical Association (AMA), Current Procedural Terminology, Appendix A Modifiers
12. AHA Coding Clinic for HCPCS 2007, Volume 7, Number 1, Page 1 Use of Modifiers 52, 73, and 74 and Anesthesia Reporting under OPPS
13. AHA Coding Clinic for HCPCS 2008, Volume 8, Number 2, Pages 1-4 Special Issue: Modifiers 52, 73, and 74
14. AHA Coding Clinic for HCPCS 2016, Volume 16, Number 1, Page 12 Appropriate Use of Modifiers for Discontinued Services under the OPPS
15. AMA CPT Assistant, September 2003, Page 3 Hospital Outpatient Reporting Part IV: Use of the CPT Modifiers ’52,’ ’58,’ ’59,’ ’73,’ ’74,’ ’76,’ ’77,’ ’78,’ and ‘91’