ED Coding and Reimbursement Alert

CompleteYour Claims for Incomplete Procedures Your physician may have to stop treating a patient before she completes the procedure - but don't abort your codes before adding modifier -52 or -53. Coders often misuse modifiers -52 (Reduced services) and -53 (Discontinued procedure), and with good reason. Technically, both modifiers can describe procedures that are cut short, and both can cite the patient's well-being or other extenuating circumstances as reasons for discontinuation. But here's the key: More often than not, modifier -53 indicates a procedure the physician aborted before completion because continuation posed a threat to the patient's health. Modifier -52, on the other hand, is more appropriate when the procedure simply requires less work, less intense work, or is atypical in some way.

According to Principles of CPT Coding, published by the American Medical Association, you should not append modifier -53 unless the physician decides to discontinue the procedure after she administers the anesthesia. Also, you shouldn't use this modifier when the surgeon's problem spurs the discontinuation - such as a scheduling conflict or equipment failure - rather than the patient's. Modifier -53: The Cure Is Worse Than the Disease You should use modifier -53 when urgent or critical situations arise that place the patient in immediate danger. "If the physician's intent is to carry out the procedure to completion - but the patient is unable to tolerate the procedure to the point that his health or well-being is at risk - and the physician ends the procedure prematurely, you should append modifier -53 to the procedure," say Carol Pohlig, BSN, RN, CPC, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia. For example, if the ED physician is using conscious sedation or anesthesia and the patient has an adverse reaction to the sedative, such as internal bleeding or failure of vital signs, she won't complete the procedure, and you should append -53.

Or let's say the physician was performing a lumbar puncture (62270*, Spinal puncture, lumbar, diagnostic) and the patient suddenly had tingling and numbness in his left leg. Out of concern for the patient's safety, the doctor terminates the procedure without retrieving cerebrospinal fluid. You would report this procedure as 62270-53 to indicate that the physician began the procedure but couldn't finish it.

For public-relations reasons, some physician groups elect not to bill for incomplete procedures that were painful for the patient, but experts disagree about this practice. Some say it's a matter of courtesy, but others think you should bill regardless of the service's outcome. "The physician should be paid for the service he or she performed, even if he was unable to complete the service," Pohlig says. "A physician must [...]