Outpatient Surgery Magazine, providing current information on Surgical Services, Surgical Facility Administration, Outpatient Surgery News and Trends, OR Excellence and more.
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ter anesthesia, the primary scheduled procedure is billed with modifi- er 73; it's billed with modifier 74 when canceled after the administra- tion of anesthesia — say, in the case of a difficult airway or some other unexpected situation that makes the surgery too risky for an outpatient setting. Payers typically cover these at 50% of the allowable when billed with a 73 modifier and 100% of the allowable when billed with modifi- er 74. Medicare, for example, covers 50% of the allowable for the pri- mary scheduled procedure when a case is canceled before the admin- istration of anesthesia, but after the wheels are rolled into the OR. Facility resources are being used and OR time is being blocked regardless of whether the surgery is performed, so you want to be vig- ilant about billing and receiving reimbursement when applicable. There are a few questions to keep in mind when reviewing your processes for canceled cases: • Is clinical staff trained to know when a canceled case is billable? For cases canceled before the administration of anesthesia, Medicare requires that wheels be rolled into the OR before the case is consid- ered billable. Many commercial payers follow Medicare's guidance and others have varying guidelines. If necessary, reach out to your provider representative for clarification. • Is appropriate documentation being captured to ensure billing can occur? As a standard, documentation by the nursing team that states the reason for the cancellation is sufficient. It is recommended, how- ever, that the physician document in the OR record the circumstances of the canceled case if you're billing a case canceled after the adminis- tration of anesthesia. • Are you communicating these cases to the biller or billing team to ensure the case is billed? Every member of your team — from clinical Coding & Billing CB 3 8 • O U T PA T I E N T S U R G E R Y M A G A Z I N E • A P R I L 2 0 1 7