Gastroenterology Coding Alert

Question: In your question last month entitled “Which Modifier Applies to This Case?” you said that modifier 53 (Discontinued procedure) was the right choice when a physician starts a procedure and then stops in the middle due to extenuating circumstances. We had always reported modifier 52 (Reduced services) in these scenarios. When does modifier 52 apply?

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Answer: Typically, modifier 52 applies when a service was performed but the work required was significantly less than what’s usually involved in performing the procedure. For instance, if the physician begins performing an EGD and comes across a lesion that prevents him from advancing the scope further, the physician may perform an EGD that’s more limited than expected and append modifier 52 to the code.

If you use this modifier, you should thoroughly explain the encounter to the payer and show why the gastroenterologist performed a more limited service than the code describes. Payers vary in the degree to which the fee paid might be reduced; 50 percent is common. Generally, it is best to bill the usual fee and let the payer apply a discount; for a non-insurance cash pay case, the fee can be reduced proportionately to the reduced work/time involved.