ED Coding and Reimbursement Alert

How should ED physicians code for a procedure that was attempted but failed? Just because you cant complete a procedure doesnt mean you shouldnt get reimbursed for it. The coding key is understanding the difference between modifiers -52 (reduced services) and -53 (discontinued procedure) and then providing thorough documentation to support the correct one.

For example, a femoral line placement was attempted, the line established, wire placed and easily threaded into the vein. The dilator was then threaded over the wire into the vein. The wire stayed in place, triple-lumen catheter was advanced over the wire, and the first several centimeters of the catheter threaded easily into the vein. But then it met resistance and the catheter kinked and was unable to be threaded farther. Can you charge for the procedure if it was terminated at this point?

This is a good example of a common scenario in the ED, explains Michael Granovsky, MD, chief financial officer of Greater Washington Emergency Physicians, a five-physician group staffing a 24,000-visit ED, in Maryland. Due to the extenuating circumstances of ED care, even skilled clinicians frequently are unsuccessful in performing certain procedures.

Additional examples of failed procedures are arthrocentesis, lumbar puncture, and arterial line placement. Another is when a foreign body in the foot was seen on x-ray, but could not be removed by exploration. The patient then required a trip to the operating room, sedation and fluoroscopy. Could you charge for the attempted foreign body removal in the ED?

The Choices: Modifier -53, Modifier -52, or No Charge

Here are three options when a procedure is not completed:

1. Use modifier -53 with a reduced charge. However, according to CPT 2001, this modifier is more suited to operating room cases that are discontinued due to circumstances that threaten the well being of the patient. But modifier -53 is not limited to the operating room. The confusion comes from the misinterpretation of a note in the CPT definition that says, This modifier is not used to report the elective cancellation of a procedure prior to the patients anesthesia induction and/or surgical preparation in the operating suite. An operating suite does not have to be an operating room, experts contend.

An example is an attempted lumbar puncture (LP), says John Turner, MD, PhD, medical director for documentation and coding of healthcare financial services at TeamHealth, an ED staffing firm in Knoxville, Tenn. During the procedure the patient develops numbness of the leg and paresthesias. The procedure is stopped before cerebrospinal fluid is retrieved. Later, the patient undergoes LP under fluoroscopy.

The LP in the ED would be coded as 62270*-53 (spinal puncture, lumbar, diagnostic; discontinued procedure).

2. Use modifier -52 and decrease [...]