AHA Coding Clinic® for HCPCS - 2016 Issue 1
Appropriate use of modifiers for discontinued services under the OPPS
The Central Office on HCPCS continues to receive requests for clarification regarding the use of discontinued modifiers under the outpatient prospective payment system (OPPS). Therefore we are publishing a recap of the reporting guidance on the use of modifiers for discontinued services under the OPPS. This information was previously published in AHA’s Coding Clinic for HCPCS, Third Quarter 2007. To provide clarity, this article will address the differences between a “failed or unsuccessful procedure” and a procedure that was discontinued. Failed/unsuccessful procedure When a procedure is considered to have “failed” or stated as “unsuccessful” this...
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Article Overview
This article explains how discontinued services are handled under the outpatient prospective payment system (OPPS) and clarifies how reporting differs from an unsuccessful procedure. It is intended for hospital outpatient coders, billing staff, and other revenue cycle professionals who need to understand facility guidance from CMS and related HCPCS/CPT reporting concepts.
Why This Topic Matters
Accurate reporting of discontinued services affects outpatient facility claims and helps distinguish procedures that were completed unsuccessfully from those that were stopped or not completed. The article is relevant to staff who review operative and procedural documentation for OPPS reporting.
Article Sections
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Failed/unsuccessful procedure
This section discusses procedures that do not achieve the expected outcome even though the service was performed. It explains the general reporting distinction between an unsuccessful result and a discontinued service.
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Discontinued procedure
This section covers procedures that were planned, started, or otherwise interrupted before completion. It describes the documentation elements that help distinguish a discontinued service from a completed service.
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Modifiers for discontinued/cancelled services
This section summarizes facility reporting guidance for discontinued or cancelled outpatient services and introduces the modifier framework discussed in the article.
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Modifier 73
This section presents CMS facility guidance for one discontinued-service modifier in the hospital outpatient setting and describes the type of circumstances addressed by the article.
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Modifier 74
This section presents CMS facility guidance for another discontinued-service modifier in the hospital outpatient setting and explains the general circumstances described in the article.
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Modifier 52
This section covers reporting of reduced, cancelled, or discontinued services when anesthesia is not planned.
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Modifier 53
This section addresses discontinuation of physician services and notes the facility outpatient hospital context discussed in the article.
What You Will Learn
- How the article distinguishes an unsuccessful procedure from a discontinued procedure
- What types of documentation elements are reviewed for discontinued outpatient services
- How CMS facility guidance is organized for discontinued or cancelled services
- Which general outpatient service scenarios are associated with the modifiers discussed in the article
Who Should Read This
- Hospital outpatient coders
- Facility billing staff
- Revenue cycle professionals
- Compliance staff
- Outpatient charge capture teams
Codes Discussed
Modifiers Discussed
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