July 26, 2018
I was excising a 2.5cm lipoma on the patient’s back in the office. One the skin was opened I observed that there was a pulsatile mass from the vein. I was concerned that this could be a large vascular structure so I discontinued the procedure to avoid potential massive bleeding? Can I code for this?
Yes, you would report 21930-53. Modifier 53 identifies that under certain circumstances, the physician or other qualified health care professional may elect to terminate a surgical or diagnostic procedure. Due to extenuating circumstances or those that threaten the well-being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued. It is recommended that you submit the claim with the usual fee and leave it up to the payor to determine if there is a reduction in payment.
*This response is based on the best information available as of 07/26/18