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Coding IR in an hospital outpatient setting

Radiology Administrator's Compliance and Reimbursement Insider, January 1, 2007

by Lolita Jones, RHIA, CCS

Interventional radiology (IR) procedures are minimally invasive, targeted treatments that use imaging for guidance. These procedures are often less risky, less painful, and have a shorter recovery time than open surgery.

Unlike traditional radiology procedures, certain IR procedures require anesthesia.

Unfortunately, CMS has not specifically addressed the use of modifier -52 in these situations.

In the absence of a formal, written directive from CMS or its fiscal intermediary (FI), hospitals need to develop an internal policy to address the use of modifier -52 or -73/-74 for discontinued IR procedures that involve anesthesia.

Guidelines for discontinued single procedures

Following are the official guidelines for modifiers -52, -73, and -74, as published in CMS Transmittal 442, Hospital Outpatient Prospective Payment System:

  • Use of modifiers -52, -73, and -74 for reduced or discontinued services: All of the definitions took effect February 22, 2005
  • For purposes of billing for services furnished in the hospital outpatient department, the definition of anesthesia includes local, regional blocks, moderate sedation/analgesia (i.e., conscious sedation), deep sedation/analgesia, or general anesthesia:
  • Modifier -73: Use this modifier to indicate that a surgical or diagnostic procedure requiring anesthesia was terminated because of extenuating circumstances or circumstances that threatened the patient’s well-being after he or she had been prepared for the procedure—including procedural premedication, when provided—and taken to the room in which the procedure was to be performed, but prior to the administration of anesthesia
  • Modifier -74: Use this modifier to indicate that a surgical or diagnostic procedure requiring anesthesia was terminated after the induction of anesthesia or after the procedure was started (e.g., the incision was made, intubation started, and the scope was inserted) because of extenuating circumstances or circumstances that threatened the patient’s well-being
  • Modifier -52: Use this modifier to indicate partial reduction or discontinuation of radiology procedures and other services that do not require anesthesia

    Scheduled/discontinued multiple procedures

    Use the following guidelines to report discontinued procedures that the hospital planned to perform along with other procedures during the same patient visit:

  • Report completed procedures as usual when hospital staff complete one or more of the planned procedures.
  • Do not report procedures that were planned but not started. If a physician starts the first procedure (e.g., scope inserted, intubation started, incision made, etc.) or the patient has received anesthesia, use modifier -74.
  • Do not report the procedure if it is terminated prior to the induction of anesthesia and before the patient is wheeled into the procedure room. The patient has to be taken to the room where the procedure is to be performed in order to report modifier -73 or -74.
  • Use modifier -73 or -74 as appropriate for discontinued pain management procedures (e.g., diagnostic and therapeutic spinal injections) if they involve the use of anesthesia.

    Following are two case studies that put these guidelines into practice. The body of the operative report in each case study includes appropriate codes/modifiers and support for their assignment.

    Case study #1: Injection report

    Procedure: Attempted three-level lumbar discogram. The procedure was aborted because the patient began vomiting once anesthesia was initiated (62290-74). Therefore, anesthesia was discontinued.

    The airway was protected and oxygen was given. The patient’s oxygen sats, which had fallen into the 80s, came back up to 98.

    At that time his vital signs were stable, and he was transferred to the recovery room.

    The patient will reschedule this lumbar discogram.

    Coding rationale: Assign code 62290-74 (Injection procedure for discography, each level; lumbar—procedure discontinued after the administration of anesthesia) to reflect the administration of the anesthesia for the scheduled discograms, although none of them were attempted.

    Case study #2: Thoracic facet arthropathy

    Operation: Right T3 through T6 thoracic facet median branch nerve block with fluoroscopic localization.

    Operative procedure: The patient was brought to the operating room and placed in the prone position. Anesthesia and monitoring were applied. I observed an adequate scout view of the thoracic spine.

    The thoracic region was prepped and draped in the usual sterile fashion (1% preservative-free lidocaine was used for local throughout using a 22-gauge spinal needle for the procedure).

    The area of pain in the thoracic region was localized with fluoroscopy from T3 through T6 (76005).

    On the right side, the needle was advanced with a 3-c. syringe of lidocaine attached.

    It was placed in the medial aspect of the T3, where the median branch lies. It was then advanced to T4, T5, and T6. At each level, 1.5 cc of 0.5% bupivacaine was injected using 20 mg of DepoMedrol in toto (64470-RT, 64472-RT, 64472-RT).

    The plan was to perform similar treatment on the left side. However, the patient had a degree of emesis and began coughing. She also moved in such a way that the needle could not hold this position.

    Therefore, the procedure on the left was aborted.

    The patient was placed on a stretcher and brought to the recovery room awake, alert, and in good condition.

    Coding rationale: Assign codes 64470-RT, 64472-RT x2, and 76005 to report the completed procedures.

    Do not report the scheduled left-side procedures, because they were not attempted. Modifiers -52, -73, or -74 are not necessary because no procedures were discontinued.

    Editor’s note: Jones is principal of Lolita M. Jones Consulting in Fort Washington, MD. E-mail her at lolitaMJ@aol.com.

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