ED Coding and Reimbursement Alert

How to pick the correct modifier for incomplete procedures When your physician stops in the middle of a lumbar puncture, you need to ask this simple question to identify the correct modifier: Why did he abort the procedure? When physicians can't complete a procedure, many emergency department coders are confused about when to use modifier -52 (Reduced services) and when to use modifier -53 (Discontinued procedure). But if you know why the physician decided not to finish the service, you can readily choose the right one. Don't Assume 'Incomplete' Equals 'Modifier' Self-Defense: Before you use one of these modifiers to describe an incomplete procedure, always make sure another code doesn't better describe the procedure the ED physician performed.

For example, suppose your ED doctor is evaluating a trauma patient using ultrasound. The physician attempts to perform a complete abdominal sonogram (76700, Ultrasound, abdominal, B-scan and/or real time with image documentation; complete), but during the procedure the patient becomes combative and the physician is able to evaluate only a single quadrant of the abdomen. In this case, rather than report 76700 with a modifier, you should instead look to 76705 (Ultrasound, abdominal, B-scan and/or real time with image documentation; limited [e.g., single organ, quadrant, follow-up]), which accurately describes the service provided. Beware of Close Payer Scrutiny You should be sure that the ED physician documents the procedures well, because the carrier may review the claims manually. The specific reduction amount of a service varies with each patient. Some claims-processing systems cannot automatically recognize and process codes appended with modifiers -52 and -53. And CMS requires payers to manually review all claims with these modifiers.

"Many payers require a copy of the report to ensure that a sufficient work effort was expended," says Cindy C. Parman, CPC, CPC-H, RCC, president-elect of the AAPC National Advisory Board and co-owner of Coding Strategies Inc. in Atlanta. "This process is more subjective and based on insurance payer guidelines." Append -53 for Stopped or Terminated Work When you append a procedure code with modifier -53, you are telling the payer that the physician could not complete the procedure because he was concerned about the patient's health and well-being, said Deborah Berry, CPC, during her presentation on modifiers at the American Academy of Professional Coders'2004 national conference in Atlanta. CPT defines modifier -53 as a stopped or terminated procedure. You can use modifier -53 only if the physician discontinues the procedure after he has prepared the patient for the service and a decision is made that the patient's well-being is at risk.

Watch out: According to CPT, if a patient elects to cancel the procedure or service "prior to the patient's anesthesia induction and/or surgical preparation," you [...]