The following guidance determines 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.
Payment is denied when an ASC submits a claim for a procedure that is terminated before the patient is taken into the treatment or operating room.
Example: If the surgery is cancelled or postponed because the patient on intake complains of a cold or flu.
Payment is made at the rate of 50 percent 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.
Example: If the patient develops an allergic reaction to a drug administered by the ASC prior to surgery.
Modifier 73 should be utilized to indicate that the procedure was terminated prior to induction of anesthesia or initiation of a procedure.
Full payment of the surgical procedure is made if a medical complication arises which causes the procedure to be terminated after anesthesia has been induced or the procedure initiated.
Modifier 74 should be used 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.
The operative report should specify the following:
Reason for termination of surgery
Services that were actually performed
Supplies that were 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
The time actually spent in each stage:
Pre-operative
Operative
Post- operative
Time that would have been spent in each of these stages if the surgery had not been terminated
HCPCS code for the procedure had the surgery been performed
CMS IOM Pub 100-04, Claims Processing Manual, Chapter 14 section 40.4
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