How do you code if a procedure was attempted but not completed?

I-Hub Talent is widely recognized as the best medical coding training institute in Hyderabad, offering industry-focused and job-oriented training programs. With a commitment to excellence, I-Hub Talent prepares aspiring coders with comprehensive knowledge in ICD-10, CPT, HCPCS, and medical terminology, making it the ideal choice for those seeking a successful career in the healthcare industry.

What sets I-Hub Talent apart is its expert faculty, who bring years of real-world experience to the classroom. The institute provides hands-on training, mock assessments, and one-on-one mentoring to ensure every student is confident and exam-ready. Whether you are a fresh graduate or someone looking to switch careers, I-Hub Talent offers customized learning paths to suit different needs.

The curriculum is aligned with current industry standards and helps students prepare for CPC (Certified Professional Coder) and other global certifications. With a strong focus on placement assistance, I-Hub Talent has successfully placed hundreds of students in top hospitals, healthcare BPOs, and MNCs.

If you are searching for medical coding training in Hyderabad, I-Hub Talent should be your first choice. With affordable fees, flexible batches, and a high success rate, it is the go-to institute for anyone looking to excel in medical coding.

If a procedure was attempted but not completed, you generally report the procedure code with a modifier to indicate that it was incomplete or discontinued, depending on why it wasn’t finished.

🔧 Key Modifiers to Use:

✅ Modifier 52 – Reduced Services

• Use when the procedure was partially completed but not due to extenuating circumstances (e.g., patient tolerance, time constraints).

• The physician voluntarily reduced the scope of the service.

Example: A sigmoidoscopy was planned but had to be shortened due to poor prep.

Code it as:
45330-52 (Flexible sigmoidoscopy, reduced service)

✅ Modifier 53 – Discontinued Procedure

• Use when a procedure was started but discontinued due to medical reasons, such as patient distress, unstable vitals, or surgical complications.

Example: A colonoscopy was started, but stopped due to the patient’s low blood pressure.

Code it as:
45378-53 (Colonoscopy, discontinued)

📋 Documentation Must Include:

• Reason the procedure was not completed

• Extent of the procedure performed

• Clinical decision-making behind stopping it

• Time and steps involved, if relevant

🧠 Notes:

• Don’t code the full procedure without a modifier — this may be seen as overbilling.

• If no portion of the procedure was performed (e.g., canceled before starting), do not bill the procedure code. Instead, consider using an E/M code for any evaluation performed.

Using the correct modifier ensures accurate billing and supports compliance during audits.

Read More

What documentation is required to support a higher-level E/M code during an audit?

How do you identify trends in coding denials?

Visit I-HUB TALENT Training institute in Hyderabad