Thursday, June 10, 2010

Surgical claim CPT modifier 74

Part - A  Level I Modifiers - 74 After Anesthesia Administration - Discontinued Ambulatory Surgical Center (ASC) or Outpatient Hospital

Description Discontinued outpatient hospital procedure AFTER the administration of anesthesia.

Required for Claims Hospital Outpatient Prospective Payment System (OPPS)

Type of Bill: 13X

Coding Guidelines Applies to surgical procedures (CPT 10000-69999) and some diagnostic services (CPT 90780-99091)


Instructions

When the surgical procedure is discontinued, after anesthesia administration in outpatient hospital or ASC only, due to extenuating circumstances or threat to patient well-being, the code is appended with a 74 modifier.

Correct Use

    Physician may terminate surgical/diagnostic procedure
        After procedure started (incision made, intubation started, scope inserted)
        After administration of anesthesia (local, regional block or general)
    Under these circumstances, intended service is prepared, but canceled and billed with usual procedure number

Incorrect Use

    Do not report elective cancellation of patient service prior to administration of anesthesia and/or surgical preparation
    Physician reporting of discontinued procedure, see modifier 53

Example

Treatment Description


CPT/Modifier

Anesthesia for procedures on esophagus, thyroid, larynx, trachea and lymphatic system of neck; not otherwise specified


00320 74

Reduced Billing: Provider performs 60% of service and appends modifier 74

Medicare Physician Fee Schedule (MPFS) allowed


$200

Bill Reduced Amount ($200 x 60%)


$120


General Guidelines

A. Modifier -74 is used by the facility 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., incision made, intubation started, scope inserted) due to extenuating circumstances or circumstances that threatened the well being of the patient.

B. For purposes of billing for services furnished in the hospital outpatient department, anesthesia is defined to include local, regional block(s), moderate sedation/analgesia (“conscious sedation”), deep sedation/analgesia, and general anesthesia.

C. This modifier code was created so that the costs incurred by the hospital to initiate the procedure (preparation of the patient, procedure room, recovery room) could be recognized for payment even though the procedure was discontinued prior to completion.

D. When multiple procedures were planned and there was a termination:

• If one or more of the procedures were completed, report the completed procedure(s) as usual. The other(s) planned procedures that are not started are not reported.

• If none of the planned procedures are completed, report the first procedure that was planned with modifier –74. The other procedure(s) is/are not reported.

Modifier -74 is used by the facility to indicate that a procedure requiring anesthesia was terminated after the induction of anesthesia or after the procedure was started (e.g., incision made, intubation started, scope inserted) due to extenuating circumstances or circumstances that threatened the well being of the patient. This modifier may also be used to indicate that a planned surgical or diagnostic procedure was discontinued, partially reduced or cancelled at the physician's discretion after the administration of anesthesia. For purposes of billing for services furnished in the hospital outpatient department, anesthesia is defined to include local, regional block(s), moderate sedation/analgesia (“conscious sedation”), deep sedation/analgesia, and general anesthesia. This modifier code was created so that the costs incurred by the hospital to initiate the procedure (preparation of the patient, procedure room, recovery room) could be recognized for payment even though the procedure was discontinued prior to completion.


Coinciding with the addition of the modifiers -73 and -74, modifiers -52 and -53 were revised. Modifier -52 is used to indicate partial reduction, cancellation, or discontinuation of services for which anesthesia is not planned. The modifier provides a means for reporting reduced services without disturbing the identification of the basic service. Modifier -53 is used to indicate discontinuation of physician services and is not approved for use for outpatient hospital services.
The elective cancellation of a procedure should not be reported.

Modifiers -73 and -74 are only used to indicate discontinued procedures for which anesthesia is planned or provided.


Effect on Payment


Procedures that are discontinued, partially reduced or cancelled after the procedure has been initiated and/or the patient has received anesthesia will be paid at the full OPPS payment amount. Modifier -74 is used for these procedures.

Procedures for which anesthesia is not planned that are discontinued, partially reduced or cancelled after the patient is prepared and taken to the room where the procedure is to be performed will be paid at 50 percent of the full OPPS payment amount. Modifier -52 is used for these procedures.

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