ED Coding and Reimbursement Alert

How to make smart decisions about appropriate modifier 52 use

Appending modifier 52 can significantly lower your payment for services such as foreign-body removal, infusion, and x-ray interpretation in the ED, so it pays to hone your instincts about when--and when not--to report it with your procedure codes. Take stock of this expert advice before you drop your next modifier 52 claim.

Add Up Procedure Percentage

Modifier 52 (Reduced services) is appropriate when procedures accomplish some result but don't fully complete the requirements of the procedure's description, says Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, senior instructor and director with the CRN Institute in Egg Harbor, N.J.

Smart: Send in documentation with a cover letter that illustrates the reduced procedure to prevent payment delays, Jandroep says.
 
Your cover letter should include an approximation of how much of the procedure you performed (such as 80 percent) to help the claims reviewer determine the value of your services. Your claims reviewer may not be an expert in ED claims, so use plain language to clearly show the work that deserves payment.

Tip: With a modifier like 52, which reduces compensation, don't submit a lower-than-usual fee--leave that up to the carrier. Submitting a reduced fee could cause the payer to slash your already diminished compensation, Jandroep says.

Remember: Don't confuse modifier 52 with 53 (Discontinued procedure). Use 53 when the physician stops the procedure because continuing would put the patient's health in danger, says Catherine Brink, CMM, CPC, president of Healthcare Resource Management Inc., in Spring Lake, N.J.

You may also distinguish the two by this general rule: If the patient received some benefit from the procedure, 52 may be more appropriate. If you don't perform enough of the procedure for the patient to receive any benefit, you-ll probably append modifier 53, Jandroep says.

Apply Your Modifier 52 Know-How

Now that you know the basics, see if you can correctly identify when to append 52 in the following scenarios.

Scenario: You receive a report with the title -Complete x-ray of the knee.- The documentation clearly states that the tech performed a three-view exam. Should you report 73564 (Radiologic examination, knee; complete, four or more views) and append 52 to indicate the reduced service?

Solution: No. You should always check your CPT manual to discern if you have a more appropriate choice before you append 52, Brink says. This is especially important for x-ray codes, which are often defined by the number of views, she adds.

Because you should base your coding on the body of the report (which explains what actually happened) rather than the title, you should see if you have a code for three views of the knee. Your best option is 73562 (Radiologic examination, knee; three views), with modifier 26 (Professional component) appended to show that the ED physician performed the interpretation only.

Count Infusion Hours Carefully

 Intravenous infusion codes designate the amount of time--by the hour--that the patient received therapy. But where does that leave you when he only received a part of an hour?

Enter modifier 52.

Example: A severely dehydrated patient receives IV infusion of fluids for two and a half hours. You would report the first hour of service with 90780 (Intravenous infusion for therapy/diagnosis, administered by physician or under direct supervision of physician; up to one hour), the second with +90781 (-each additional hour, up to eight hours), and the last half hour with 90781-52, to indicate that the patient didn't receive a full hour of administration.
 
For private payers, you should report code 90781 to describe each additional hour that the physician administers or directly supervises administration of the infusion, according to the July 2001 CPT Assistant. The purpose of 90781 is to accompany code 90780--so you should never report 90781 alone. Note that CPT will be deleting these two codes in 2006, and that you can only report them to private payers. Medicare does not accept them at all.

Remember these four tips when reporting codes 90780 and 90781:
                                                                   
1. You can report 90781 for each additional hour up to eight hours--but not beyond eight hours.
 
2. You shouldn't report the prolonged service codes (99354-99357) in addition to 90780 and 90781, because these are time-based codes. 

3. When infusion lasts more than one hour but less than a full additional hour, you can append modifier 52 to 90781. This will indicate that the time beyond the first hour was less than one hour.
 
4. Codes 90780 and 90781 include evaluation of the patient's response to the infused substance. They also include intravenous catheter placement. Therefore, you shouldn't report these services separately.

Describe Unfinished Procedures

In some instances, the physician is unable to resolve the patient's injury in the ED and requires a specialist to perform surgery or further care. For example, suppose a welder presented to the ED with a small, thin slice of metal embedded in his hand. The physician makes an incision but has trouble finding and extricating the metal piece, so she sutures the patient's hand and refers him to a hand surgeon.

You want to acknowledge the work involved in the physician's exploration of the wound, but she didn't complete the foreign-body removal. To demonstrate this effort to the payer, you would append modifier 52 to the FBR code: 10120-52 (Incision and removal of foreign body, subcutaneous tissues; simple; reduced services).

Lesson: Don't automatically append modifier 52 every time your report suggests a service that doesn't quite meet the CPT descriptor. Check for why the physician shortened the procedure and keep track of guidance telling you what services Medicare believes each code represents.