ED Coding and Reimbursement Alert

When a procedure is terminated due to patient intolerance or anatomical variance, the CPT Codes that normally would be reported seems inaccurate because it reflects completing the entire procedure. Instead, ED coders should append the procedure codes with either modifier -52 (Reduced services) or -53 (Discontinued procedure) to indicate that only a portion of the procedure was performed.

Modifier -53:Well-Being of Patient Threatened

According to the AMA, when an ED physician stops a procedure because the patient is not tolerating it, coders should use modifier -53. CPT 2002 states physicians may terminate surgical or diagnostic procedures: "Due to extenuating circumstances or those that threaten the well-being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued." Because the modifier's definition later refers to an "operating suite," some coders are concerned that modifier -53 does not apply to ED services. That is not the case. When a procedure is discontinued because it threatens the patient's welfare, you should use modifier -53 regardless of location.

According to Carol Sissom, BS, CPC, senior consultant with Health Care Economics Inc. in Indianapolis, modifier -53 is typically assigned when an urgent or critical situation arises. "Perhaps the ED physician is using conscious sedation and the patient has a reaction to the anesthesia," she says. "In other instances, the patient might suffer from internal bleeding or his vital signs may begin to fail. All of these might be indications that the procedure should be halted. Modifier -53 could then be used."

For example, an emergency physician is performing a lumbar puncture (62270*, Spinal puncture, lumbar, diagnostic) when the patient develops tingling and numbness in her right leg. The doctor aborts the service before cerebrospinal fluid is retrieved. You should report 62270*-53.

Modifier -52:Unable to Complete Full Procedure

At other times, a procedure can't be completed because of anatomical variances or other circumstances that interfere with progress. "The physician begins a procedure but for some reason can't complete it," says Tammy Akason, MA, CPC, manager of reimbursement and pricing for MeritCare Health System in Fargo, N.D. "If the provider elected not to do part of the procedure or if the case presented did not require a full procedure, modifier -52 is applicable." Two examples illustrate when to use modifier -52:

An ED physician attempts to place a femoral line in a young patient. The line is established, and the wire is placed and threaded into the vein. The dilator is then threaded over the wire into the vein. The triple-lumen catheter is successfully threaded into the first several centimeters of the vein. However, the physician meets resistance, the catheter kinks, and the procedure is discontinued. Because the service cannot be completed but termination is not the result of a threat to the patient's health, modifier -52 is appropriate. You should report 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).

An x-ray of the upper arm of an accident victim reveals a foreign body imbedded in the limb, but the physician cannot retrieve it during exploration (20103, Exploration of penetrating wound [separate procedure]; extremity). The patient is transferred to the operating suite, where a surgeon completes the procedure. Because the ED physician attempted to remove the foreign body and failed, you should bill 20103-52.

Consider Alternative Codes

A partial service, such as an abbreviated colonoscopy, is sometimes more accurately described by a different code than the original procedure warranted. Typically, a colonoscopy (45378, Colonoscopy, flexible, proximal to splenic fixture; diagnostic, with or without collection of specimen[s] by brushing or washing, with or without colon decompression [separate procedure]) includes examination of the entire colon from the rectum to the cecum (the segment below the terminal ileum that forms the first section of the large intestine) and may advance into the ileum. If the ED physician is unable to advance beyond the splenic flexure, the procedure can instead be described as a flexible sigmoi-doscopy (45330, Sigmoidoscopy, flexible; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]), which includes viewing the entire rectum, the sigmoid colon, the descending colon and some parts of the transverse colon using a fiberoptic scope.

Note: You should be careful when choosing an alternative code. CPT 2002 instructions state, "Select the name of the procedure or service that accurately identifies the service performed. Do not select a CPT code that merely approximates the service provided." The directions previously noted that coders should "select the name of the procedure or service that most accurately identifies the service performed." When a procedure isn't completed, modifier -52 or -53 is usually appropriate. Under circumstances other than terminated procedures, CPT requires that an unlisted-procedure or -service code be reported.

Some Opt Not to Charge

Some ED physicians and coding specialists recommend not billing for a failed procedure under certain rare circumstances. If only a minor portion could be completed, it might be appropriate to forego coding and billing the procedure.

But you should usually bill the procedure with the correct modifier so the professional fees match the facility fee. In addition, Sissom says, the ED physician performed a particular portion of the service and deserves to be fairly compensated.

Who Reduces the Charges?

Some ED practices decrease their charges before submitting a claim with modifier -52 or -53. Instead, Sissom says, a paper claim should be submitted with detailed documentation so the payer can ascertain what percentage of the procedure was completed and the appropriate payment.

Other practices proactively reduce their fees, particularly with modifier -52, Akason says. "Our practice policy states that if modifier -52 applies because part of a procedure was not done, we will reduce the price before submitting the claim. We determine the price based on what portion of the service was not completed. Payers do not usually further reduce our reimbursement for modifier -52." Her practice does not reduce its fee when modifier -53 applies.

Note: When reporting modifier -52, ask your Medicare carriers and private insurers whether you should reduce your charges. Ultimately, the payer decides the payment.