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.

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.

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."

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 should not use modifier -53.

Example: A child with a high fever presents to the ED. The ED physician prepares him for a lumbar puncture, positions him, and injects local numbing medicine. The doctor inserts the spinal needle, and the patient develops severe pain, leg tingling, and numbness, followed by diaphoresis and vomiting. Before completion, the physician halts the procedure due to concern about the patient's well-being.

"In this case, or one similar, I would append the -53," says Sandra Pinckney, CPC, coding supervisor at Certified Emergency Medicine Specialists in Grand Rapids, Mich. "I tend to use -53 only when the patient's well-being is threatened."

According to CPT, "Under certain circumstances a service or procedure is partially reduced or eliminated at the physician's discretion. Under these circumstances, the service provided can be identified by its usual procedure number and the addition of the modifier '-52,'signifying that the service is reduced. This provides a means of reporting reduced services without disturbing the identification of the basic service."

Modifier -52 has two functions: to indicate a reduced service or to indicate a failed procedure.

Example 1: An accident victim receives an x-ray of his upper arm. The ED physician discovers a foreign body imbedded in the patient's limb, but despite several attempts is unable to remove it during exploration of the arm (20103, Exploration of penetrating wound [separate procedure]; extremity). The doctor sends the patient to an operating suite where a surgeon completes the procedure.

Modifier -52 tells the payer that the physician elected not to perform a portion of the procedure that the CPT code definition describes.

Example 2: Suppose the ED physician starts to place a femoral line in a patient. He establishes the line, places the wire and threads it into the vein, and threads the dilator over the wire. He threads the triple-lumen catheter into the first few centimeters of the vein -- but then the catheter kinks. He discontinues the procedure.

In this case, you could report 36556-52 (Insertion of non-tunneled centrally inserted central venous catheter; age 5 years or older). However, you may choose not to bill at all, depending on your practice's public-relations policy.

Example 3: "Let's say that a lumbar puncture is being performed on an adult who simply won't lie still or is being otherwise uncooperative -- maybe due to pain," Pinckney says. The doctor cannot complete the procedure. "In this case, I would append -52 to the 62270 (Spinal puncture, lumbar, diagnostic)," she says.