Revenue Cycle

Scenario: Billing for a Medicare patient's hernia repair

Medicare Update for CAHs, May 16, 2012

Situation: Jonathan, a 68-year-old Medicare patient, presents to a hospital’s outpatient surgery department for a surgical repair of an initial reducible inguinal hernia (CPT® code 49505) for which the hospital normally charges a flat fee of $5,000. The physician canceled the hernia repair due to an unexpected drop in Jonathan’s vital signs after he had been taken to the procedure room but before induction of anesthesia. How should the hernia repair be billed to Medicare, including the CPT code, modifier, and charges?

Answer: Report CPT code 49505-73 and reduce the charges  to reflect the reduced cost since the procedure was not completed. Modifier -73 (procedures discontinued prior to anesthesia) does not trigger a payment reduction for a CAH like it does for a PPS hospital

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