General Surgery Coding Alert

When you can’t quite report a procedure code because it describes more than your surgeon actually performed, do you know which modifier can get you out of the bind?

Let our experts guide you through several examples of partial service cases with a toolkit of modifiers to describe every scenario you may face.

Add 26 for Professional Component Only

Some procedures describe both the physician’s work and a technical component, and sometimes you’ll need to bill the components separately.

Modifier 26 (Professional component) identifies the professional work portion of the procedure. When you append 26 to a code, “it reduces payment to just the physician’s work,” explains Kelly Dennis, CANPC, CHCA, CPC, CPC-I, owner of Perfect Office Solutions in Leesburg, Florida. The payment doesn’t include the cost of technical components such as equipment and supplies used in the procedure.

When: Splitting a code into its professional and technical component is necessary when your surgeon uses someone else’s facility and/or equipment. You’ll use modifier 26 mostly in office or other outpatient facilities when the equipment is the property of the clinic or facility and not the physician,” explains Suzan Hauptman, MPM, CPC, CEMC, CEDC, senior principal of ACE Med Group in Pittsburgh.

For example: The surgeon places an arterial line under ultrasound guidance. Report the service as 36620 (Arterial catheterization or cannulation for sampling, monitoring or transfusion (separate procedure); percutaneous) and +76937 (Ultrasound guidance for vascular access requiring ultrasound evaluation of potential access sites, documentation of selected vessel patency, concurrent realtime ultrasound visualization of vascular needle entry, with permanent recording and reporting (List separately in addition to code for primary procedure)). You should append modifier 26 to +76937 because the professional component of the service is the supervision and interpretation of the guidance.

Caution: The Office of Inspector General (OIG), “watches the professional services, and the 26 modifier, very carefully,” Hauptman says.

To ensure proper modifier 26 use, Hauptman encourages coders to follow these basic guidelines:

• “Understand what is included in the description of the code — some codes are for only the professional component, and you wouldn’t need the 26 modifier.
• “Understand exactly what your physician did and read the documentation associated with the service.
• “Know what equipment is owned by your practice and what is owned by the various facilities where your doctor sees patients.
• “Understand the relationship your physician has with the facility, as they might bill the global fee and pay the physician based on a contract.”

Turn to 54 for Surgical Component Only

Surgical codes include pre-op, intraoperative, and post-op care. When your surgeon doesn’t carry out all steps of the procedure during the global period, you’ll need to turn to a different modifier to indicate partial services.

Use modifier 54 (Surgical care only) “when the physician provides only the surgical procedure — pre-op and intraoperative care — and another physician provides post-op care,” says Catherine Brink, BS, CPC, CMM, president of Healthcare Resource Management in Spring Lake, New Jersey.

The most common situation that calls for modifier 54 is when the patient doesn’t live in your area and won’t be present for postoperative care.

No surprise: The surgeon generally has an agreement with the patient and their payer about providing only surgical care. The surgeon should know that the patient will obtain postoperative care elsewhere before taking on the surgery, and that should be documented in the medical record.

Pay: Your surgeon should expect about 71 percent of the allowed relative value units (RVUs) for the procedure code when billed with modifier54.

Use 52 for Reduced Services

Modifier 52 (Reduced services) indicates that a service was partially reduced or eliminated at a physician’s discretion.

If a provider plans or expects a reduction in the service, you should append modifier 52 to the appropriate CPT^® code. Modifier 52 may reflect that the surgeon performed a bilateral procedure, but intentionally addressed only one side. If that’s the case, you may append modifier 52.

Appendix A in the CPT^® manual states, “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.”

For instance: The surgeon performs a vestibuloplasty on the right side of the mouth to reconstruct the vestibule following traumatic injury to the right side of the face. You should report that service as 40843 (Vestibuloplasty; posterior, bilateral) with modifier 52, because the surgeon does not perform a bilateral procedure in this case.

Don’t: If the surgeon halts a procedure after anesthesia due to clinical circumstances, such as a drop in blood pressure, you shouldn’t use modifier 52. Those circumstances point to modifier 53 (Discontinued procedure) instead.