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Bill canceled procedure separate from performed procedure

APCs Weekly Monitor, May 19, 2006

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Bill canceled procedure separate from performed procedure

QUESTION: Staff place a Medicare patient scheduled to undergo kyphoplasty under anesthesia, but the physician does not perform the procedure that day. Three days later, a physician performs the procedure in its entirety.

Since the patient was readmitted after three days, does this change how we should code the procedure? What CPT codes/modifiers do you recommend? Here is the procedure documentation:

Impression: Canceled planned lumbar kyphoplasty of one vertebral body secondary to tachycardia.

Anesthesia: Intravenous administration of 0.5 mg of Versed and 25 mcg of Fentanyl was carried out.

ANSWER: Hospitals that treat Medicare patients are not subject to surgical or global follow-up days. These apply to physician/professional services. Treat and bill each visit individually and appropriately. Make sure that codes and charges for each visit correctly report the services rendered to the patient while he or she is a hospital patient.

Furthermore, the question seems to imply that there is a three-day window similar to the inpatient prospective payment system. This also does not apply for outpatient billing. Therefore, your hospital should bill in the following manner:

Report the planned/cancelled lumbar kyphoplasty with the appropriate CPT code and append modifier -74 (discontinued outpatient procedure after anesthesia administration). Many FI's require you to report a diagnosis code of V64.1 (surgical or other procedure not carried out because of contraindication) on the UB-92. Facilities must report the CPT for the intended procedure. In this case, modifier -74 indicates that the procedure was cancelled after the administration of anesthesia. For procedures cancelled prior to administration of anesthesia, append modifier -73.

In order for facilities to report modifiers -73 and -74, the patient must be in the room where the procedure will be performed. If the procedure was cancelled in pre-op or another holding area, do not report the procedure code or use a modifier. However, we recommend that you contact your FI because it may be appropriate to report an E/M code according to your facility E/M guidelines.

Refer to Medlearn Matters for a couple helpful articles regarding the use of modifier -73 and -74. You can find them at the CMS Web site: http://www.cms.hhs.gov/MLNMattersArticles/

Regarding the procedure performed three days later without problem, code this procedure and bill it separately as a separate visit.

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