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 [...]