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 the charge accordingly. As a rule, modifier -52 is used if the physician is unable to complete the procedure for other reasons, such as the anatomy of the patient. Modifier -52 would not be used if the patient experiences an adverse side effect to the procedure. In the original scenario, all steps were performed except further threading of the triple lumen. The partially completed procedure would be coded as 36489*-52 (placement of central venous catheter [subclavian, jugular, or other vein] [e.g., for central venous pressure, hyperalimentation, hemodialysis, or chemotherapy]; percutaneous, over age 2; reduced services).

3. No charge at all. Sometimes billing for a failed procedure can be a political issue. Many ED physicians do not bill for an unsuccessful procedure and will not code a painful procedure that was unsuccessful.

However, this can cause problems because the official coding guideline for the facility is to code the procedure even if the desired result was not achieved. The reasoning for this is to ensure that the supplies, time and the attempt were documented. Therefore, if the doctor does not code, facility procedure codes may not match the professional fee coding. Strictly from a coding point of view, the rule of common sense would apply to these scenarios, Granovsky explains. If a majority of the major steps of the procedure were performed and documented, then using a reduced charge seems appropriate. If very little was done, then not charging seems correct.

Four Tips to Avoid Denials

When using modifiers -52 and -53, follow the following tips to avoid denials:

1. Dont file electronically. If you use -53 or -52 you cant file the claim electronically because HCFA guidelines require payers to manually review these incomplete or canceled procedures. Thus, solid documentation is extremely important for getting paid because the payer calculates the amount to pay based on how much of the procedure was completed.

Susan Callaway, CPC, CCS-P, an independent coding consultant and educator in North Augusta, S.C., says, The insurance company will determine the reduction. Do not increase or reduce your own fees. Otherwise, you may receive more or less than the reimbursement to which you are entitled.

2. Provide detailed, solid documentation. This documentation should include a description of the patients condition, what the planned procedure was, what the extenuating circumstances were, what happened and what time and effort were involved. You should include one paragraph summarizing medical necessity and one summarizing the procedure that was planned and why it was discontinued.

3. Dont confuse reduced services with reduced charges. Dont reduce the fee yourself when filing the claim. Carriers will review the claim and often identify the modifier and then reduce the fee reported.

4. If there is a CPT code that describes the services you rendered, use it. Use modifier -52 only when another existing CPT code does not completely describe what services were given or what procedure was performed.

An example is a colonoscopy (45378) that is partially completed and is advanced as far as the splenic flexion, to the extent that the procedure meets the definition of a sigmoidoscopy (45330). It is appropriate to bill 45330 instead of coding it as a 45378 with a -52 modifier.