With the increased utilization of minimally invasive glaucoma surgery (MIGS) surgery in combination with cataract procedures, we find more instances where part of the planned procedure cannot be completed. Correct billing depends on why the procedure was stopped.

Q. Can you give an example?

A. An ophthalmic surgeon performs a MIGS that involves cataract surgery and concurrent implantation of an aqueous drainage device (ADD) such as Glaukos’ iStent inject or Ivantis’ Hydrus Microstent. This combined procedure is usually coded as 66991 (Extracapsular cataract removal with insertion of intraocular lens prosthesis, manual or mechanical technique; with insertion of intraocular anterior segment aqueous drainage device, without extraocular reservoir, internal approach). In this example, although the cataract procedure was completed without any difficulty, the placement of the ADD was not successful and it had to be removed from the eye before the end of the surgery.

Q. How should we bill the incomplete procedure?

A. In the modifier appendix of the CPT manual, CPT includes a provision for a discontinued procedure “… due to extenuating circumstances or those that threaten the well-being of the patient.” Novitas, a Medicare Administrative Contractor for several states, wrote in its fact sheet for surgical modifiers that “discontinued due to elevated blood pressure” is a credible justification. This is described by modifier 53 (Discontinued procedure) for the surgeon and either modifier 73 (Discontinued outpatient hospital/ambulatory surgery center procedure prior to the administration of anesthesia) or 74 (Discontinued outpatient hospital/ambulatory surgery center procedure after administration of anesthesia) for the ambulatory surgery center.

In this case, the operative report describes that the cataract portion of the operation was successful but that the MIGS procedure was not performed successfully. There are many potential reasons why the surgeon was not able to place the ADD, including: difficulty with visualization, equipment malfunction, defective implant, surgeon inexperience, poor patient selection or intraoperative misadventure.

While billing the planned procedure — 66991 — with modifier 53 is plausible, the use of modifier 53 should be reserved for a case that is terminated for life-threatening or sight-threatening reasons rather than failure to complete it.

Q. When is modifier 53 used?

A. Take, as an example, an inadvertent incision in an artery within the iris root resulting in a significant hemorrhage in the anterior chamber obscuring the surgeon’s view of the anterior chamber angle; additional viscoelastic did not stop the bleeding, then there is an acute threat to the patient’s well-being that warrants discontinuation of the procedure. Such a situation necessitates a longer and more detailed operative report that explains what went wrong, why and how it was handled. This could support 66991-53.

Q. How do you document support for modifier 53?

A. CMS instructs that, “the operative report should specify the following:

• Reason for termination of the surgery;
• Services actually performed;
• Supplies actually provided;
• Services not performed that would have been performed if surgery had not been terminated;
• Time actually spent in each stage, eg, pre-operative, operative, and postoperative;
• Time that would have been spent in each of these stages if the surgery had not been terminated; and
• HCPCS (or CPT) code for procedure had the surgery been performed.”

While an argument can be made that any extenuating circumstances, no matter how small, might support the use of modifier 53, surgeons prefer to celebrate their success rather than highlight their failures. As a practical matter, the resolution of a claim for a discontinued procedure will rely on the payer’s assessment of the portion of the procedure completed. Was it half? A quarter? In this example, none of the MIGS procedure was completed, so very little value would likely be ascribed to it.

Q. What is the billing alternative?

A. If the reason the ADD implant is not implanted successfully does not support modifier 53, it is reasonable to bill only for the cataract surgery (66984) — that is, the completed procedure.

Q. But then what happens to the ASC payment?

A. If the ADD procedure cannot be supported but cataract surgery can, then reimbursement to the ASC is for 66984 only. No reimbursement is provided for the ADD device. It may be possible for the ASC to obtain a refund or a replacement product from the ADD manufacturer for the unused device. OM