Payment for Terminated Procedures

40.4 - Payment for Terminated Procedures (Rev. 11793; Issued:01-19-23; Effective: 02-21-23; Implementation: 02-21-23) The following criteria determine the appropriate ASC facility payment for a scheduled surgical procedure that is terminated due to medical complications which increase the surgical risk to the patient A. Contractors deny payment when an ASC submits a claim for a procedure that is terminated before the patient is taken into the treatment or operating room. For example, payment is denied if scheduled surgery is canceled or postponed because the patient on intake complains of a cold or flu. B. Contractors pay 50 percent of the rate if a surgical procedure is terminated due to the onset of medical complications after the patient has been prepared for surgery and taken to the operating room but before anesthesia has been induced or the procedure initiated (use modifier 73). For example, 50 percent is paid if the patient develops an allergic reaction to a drug administered by the ASC prior to surgery or if, upon injection of a retrobulbar block, the patient experiences a retrobulbar hemorrhage which prevents continuation of the procedure. Although some supplies and resources are expended, they are not consumed to the same extent had anesthesia been fully induced and the surgery completed. Facilities use a 73 modifier to indicate that the procedure was terminated prior to induction of anesthesia or initiation of the procedure. C. Contractors make full payment of the surgical procedure if a medical complication arises that causes the procedure to be terminated after anesthesia has been induced or the procedure initiated (use modifier -74). For example, A/B MACs (B) make full payment if, after anesthesia has been accomplished and the surgeon has made a preliminary incision, the patient’s blood pressure increases suddenly and the surgery is terminated to avoid increasing surgical risk to the patient. In this case, the resources of the facility are consumed in essentially the same manner and to the same extent as they would have been had the surgery been completed. Facilities use a 74 modifier to indicate that the procedure was terminated after administration of anesthesia or initiation of the procedure. An ASC claim for payment for terminated surgery must include an operative report kept on file by the ASC, and made available, if requested by the contractor. The operative report should specify the following: • Reason for termination of surgery; • Services actually performed; • Supplies actually provided; • Services not performed that would have been performed if surgery had not been terminated; • Supplies not provided that would have been provided if the surgery had not been terminated; • Time actually spent in each stage, e.g., pre-operative, operative, and post- operative; • Time that would have been spent in each of these stages if the surgery had not been terminated; and • HCPCS code for procedure had the surgery been performed. D. Prior to January 1, 2008, contractors deducted the allowance for an unused IOL prior to calculating payment for a terminated IOL insertion procedure. E. Beginning January 1, 2008, payment for the IOL is included in payment for the surgical procedure to implant the lens. F. Beginning January 1, 2008, contractors apply a 50 percent payment reduction for discontinued radiology procedures and other procedures that do not require anesthesia. Facilities use the -52 modifier to indicate the discontinuance of these applicable procedures. G. Beginning January 1, 2008, ASC surgical services billed with the -52 or- 73 modifier are not subject to the multiple procedure discount.