ED Coding and Reimbursement Alert

Think you know when to report reduced services and when to report a discontinued procedure? Take this quiz to find out for sure.
 
In each of the following scenarios, decide whether you should append modifier -52 or -53 for the ED physician's services.

Scenario 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 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.
 
Answer: While the surgeon was eventually able to retrieve the foreign body, the ED physician was not. Because the reason for the ED doctor's shortened service was not based on imminent risk to the patient's health, you should report 20103-52.


Scenario 2:
A patient is in the middle of a computed tomography (CT) scan when he has a claustrophobic attack. The physician cannot complete the procedure due to the patient's apprehension.
 
Answer: This situation might seem deceptive because the patient's physical health is not in imminent danger, but the phobia may threaten his immediate well-being in a more general sense if the physician were to continue. Your best bet would be to report modifier -52 because you may have more difficulty justifying -53 to your carrier.



Scenario 3:
During the drainage of a peritonsillar abscess (42700*, Incision and drainage abscess; peritonsillar), the patient begins bleeding and has difficulty breathing because an obstruction compromises the airway. The doctor halts the procedure due to concern for the patient's safety.

Answer: No doubt here - modifier -53 is the way to go. The physician stopped the procedure midway because of impending danger to the patient's life, so you'd have no trouble explaining why you couldn't complete the service.