General Surgery Coding Alert

Knowing why the physician halted the procedure matters for modifiers -52/-53 When a surgeon provides a less-than-total service, either by choice or necessity, you can quickly decide between modifiers -52 and -53 to describe the situation by asking yourself, "Why did the physician stop the procedure?" If Planned or Electively Reduced,Choose -52 When 1) the surgeon plans or expects a reduction in the service, or 2) the surgeon electively cancels the procedure prior to completion, you should append modifier -52 to the appropriate CPT code. Modifier -52 (Reduced services) -- 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 (CPT 2004, Appendix A). To apply modifier -52, the reduction of services must have occurred by choice (either the surgeon's or the patient's) rather than necessity.

"For example, the surgeon may determine that it is appropriate to provide the service at a lesser level than the complete description indicates, or the patient may elect to cancel the procedure," says Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, director and senior instructor for CRN Institute, an online coding certification training center based in Absecon, N.J. Example A: The surgeon performs a pelvic lymphadenectomy on the right side. In this case, because CPTdoes not contain a code describing unilateral lymphadenectomy, you should report 38571 (Laparoscopy, surgical; with bilateral total pelvic lymphadenectomy) and append modifier -52 to describe a reduced service. Example B: The surgeon begins colonoscopy (45378, Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen[s] by brushing or washing, with or without colon decompression [separate procedure]), which includes an exam of the entire colon, from the rectum to the cecum (and possibly into the ileum). During the exam, however, the surgeon finds he cannot advance the examination beyond the splenic flexure. In this case, you should report 45378-52 to denote the "reduced" service, according to CPTguidelines. Note: Medicare stipulates unique guidelines concerning incomplete colonoscopy, and recommends reporting 45378-53 rather than 45378-52. Although this runs directly contrary to CPT's specific instructions, you must follow Medicare guidelines to receive payment from Medicare payers. If the Patient Is at Risk, Append -53 When the physician terminates a procedure because continuation of that procedure puts the patient's health at risk, you should append modifier -53 to the appropriate CPT code. You should not append modifier -53 if the surgeon electively cancels a procedure prior to the administration of anesthesia or surgical preparation in the operating room, according to CPT guidelines. Modifier -53 (Discontinued procedure) -- Under certain circumstances, the physician [...]