Q. How do we code a cancelled procedure? In this case, the patient was in our clinic for lumbar spinal nerve root injection (CPT code 64483). But his blood sugar was very low, and he was having trouble breathing. So the physician cancelled the procedure, and we called for an ambulance. The patient was stabilized until the ambulance arrived to transport him to hospital.
A. Modifier 53 would be the most appropriate for this situation. Here is the full definition:
Discontinued Procedure: 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 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/ambulatory surgery center (ASC) reporting of a previously scheduled procedure or service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for ASC hospital outpatient use).
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