Anesthesia Coding Alert

Pain management specialties might make use of modifier 52 as well.

The situation is bound to happen: A patient undergoing surgery has complications, and your anesthesiologist must stop his services. Are you prepared to recognize a situation that calls for modifier 53 (Discontinued procedure) or even modifier 52 (Reduced services)? Learn the specific criteria for reporting each modifier to ensure successful coding every time.

Patient Status Often Determines 53 Use

You will use modifier 53 when a procedure ends due to a threat to the patient's well-being or other extenuating circumstances. For example, the surgeon performs a preop assessment, but during the evaluation he detects a carotid bruit (785.9, Other symptoms involving cardiovascular system), so he delays the surgery indefinitely until a better evaluation can be made.

Documentation clue: You can only use modifier 53 after anesthesia administration and/or a surgical preparation took place, and the procedure was actually started. You should consider the procedure discontinued when anesthesia ends early. "If any modifier is to be used, 53 is the most appropriate," says Scott Groudine, MD, professor of anesthesiology at Albany Medical Center in New York.

Example: A patient is being prepared for a routine surgery but has not yet been induced. Another patient develops chest pains and must be induced for surgery immediately, so your anesthesiologist must cancel the first procedure to attend to the second patient's procedure. You should report 01999 (Unlisted anesthesia procedure[s]) with modifier 53, Groudine recommends.

You should let the payer reduce the fee on services to which you attach modifier 53. Otherwise, you risk additional payment reductions.

Bottom line: When reading the operative report of a discontinued service, simply look at the reason for the discontinuance. If it indicates an extenuating circumstance occurred, use modifier 53.

Facility difference: If you are coding only for facility  payment, such as for an ambulatory surgical center (ASC),use modifiers 73 (Discontinued outpatient procedure prior to anesthesia administration) or 74 (Discontinued  outpatient procedure after anesthesia administration) instead of modifier 53.

Turn to 52 for 'Physician Discretion'

Although modifier 52 may not apply to anesthesia, it might apply to pain management specialists. You should use modifier 52 when your pain management specialist, while performing a service or procedure, chooses to partially reduce or eliminate a portion of the code's requirements. "Under certain circumstances a service or procedure is reduced at the physician's discretion. This decision can be made prior to or during the procedure.

You should use modifier 52 when services your pain management specialist performs are less than those described by the code. In such a case, you must be certain that there is no designated CPT code to describe the lesser procedure.

Tip: Let the payer reduce the fee for the procedure when you use modifier 52. Do not apply the fee reduction on the claim. If you do, the payer may still reduce your reimbursement because of the modifier, and you may then receive a double fee reduction.