Our surgeon planned for a patient to have a laparoscopic cholecystectomy. Following exploration of the area in the OR, the surgeon aborted due to significant infectious process. We reported the cholecystectomy code with a modifier 53. The patient returned to the OR this week, and we are wondering if we should use modifier 78 or 58. What recommendation do you have?
Answer:
If the case was aborted after the exploratory part of the procedure, report the laparoscopic exploration code, 49320 Laparoscopy, abdomen, peritoneum, and omentum, diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure). For the second procedure, which we assume by your question is occurring within the global period of the exploratory laparoscopy, append modifier 58 to the appropriate cholecystectomy CPT code to indicate a return to the OR for a planned/related procedure.
Use modifier 53 when the surgical procedure is aborted related to life-threatening complications.
thank you for sharing the information. It was helpful.
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