It’s an unfortunate fact of medicine that things don’t always go to plan. A procedure date may be planned months in advance, the rest of the hospital’s surgery schedule built around it, only for there to be a last-minute issue with the patient’s vitals, forcing the operation to be postponed. Though the procedure may be cancelled, the hospital still took the patient’s vitals and is thus deserving of compensation for these tests at the very least. If billed correctly, the facility may even receive payment for an operation that was altered at the last second or even not completed altogether.

For simple diagnostic tests and minor procedures that do not require anesthesia, adding modifier 52 to the root CPT code will denote “partial reduction, cancellation, or discontinuation” if the providers chooses to change the planned service. This same modifier works for any bilateral procedures that get reduced to only one side at the last minute. If, however, the procedure is specified as “bilateral or unilateral,” then this modifier would not apply. Conversely, if the procedure must be cancelled or changed because the patient is at risk and the provider is compelled to cancel the procedure, then modifier 53 (“discontinued procedure”) is used.

Regardless of the reason, it is essential to document the factors that led to the cancellation of any procedures. The more evidence there is, the easier time a facility will have getting its proper reimbursement. Additionally, all relevant aspects of the procedure should be documented, even if the procedure was not completed. For example, making note of not just the scheduled surgery time but also the time the patient officially entered the operating room (if applicable) is a good way to make sure the documentation is complete. When in doubt, recording too much information is always better than the alternative.