General Surgery Coding Alert

Some general surgery coders have problems distinguishing between modifiers -52 (reduced services) and -53 (Discontinued procedure), in part because the CPT descriptors for both are similar in many ways. There are, however, significant differences between these two modifiers, and by following a simple guideline coders can keep them straight: Modifier -52 should be attached to codes when the surgeon completed the procedure but did not fulfill all of its requirements, and modifier -53 should be used for procedures that are terminated by the surgeon, typically because of the patients condition.

For example, a surgeon would use modifier -52 in a co-surgery situation during which a procedure is performed that includes opening and closing the patient. Because another surgeon performing a separate procedure opened and closed the patient, the first surgeon bills for the procedure with modifier -52 attached, to indicate that the procedure was performed without opening and closing.

Another example in which a surgeon would use modifier -52 correctly would be a bilateral pelvic lymphadenectomy (38571, laparoscopy, surgical; with bilateral total pelvic lymphadenectomy) performed only on one side. In this instance, the procedure should be coded 38571-52 and submitted with a cover letter to explain why only one side was done.

Modifier -52 is not used for an incomplete procedure, but rather, is used when the physician completed what he or she set out to do but did so performing less than the complete procedure. If the surgeon, for instance, only performed four of six components of the procedure, reporting it without a -52 modifier would be inappropriate, says Barbara Cobuzzi, MBA, CPC, CCS-P, a coding and reimbursement specialist in Lakewood, N.J.

If you dont do exactly what the code describes, you need to inform the carrier that you didnt do it, which is what modifier -52 does, she says, noting that when it is used appropriately, the surgeon cant be held responsible for not reporting the procedure correctly.

Another, more delicate use of modifier -52 is for procedures that have no established CPT code. In certain situations, instead of using an unlisted procedure code, surgeons may prefer to use the code of a similar, but more encompassing listed procedure and attach modifier -52 to it, Cobuzzi says.

Using the -52 modifier in this manner, however, can be dicey. If CPT, Medicare or your private carrier instructs you to use an unlisted code, attaching modifier -52 to a more complex procedure in this manner would be inappropriate, says Susan Callaway-Stradley, CPC, CCS-P, an independent coding consultant and educator in North Augusta, S.C. Anytime modifier -52 is billed out, make sure your documentation supports the claim. Many carriers want to see the documentation before they consider reimbursing procedures with modifier -52 attached, Callaway-Stradley adds.

When submitting claims with modifier -52 attached, Cobuzzi recommends you bill the procedure out at the full fee and include a simple cover letter that explains what wasnt done and why. If possible, she adds, the percentage of the full procedure that was performed should be indicated to assist the payer in determining how much to reduce the fee.

Unfortunately, you have to leave it up to the payer to set the fee, Cobuzzi says, noting that if you take your own percentage off the full fee, the carrier may reduce your reimbursement by a further percentage of that.

Modifier -53 Triggers Automatic Review

The key phrase in the CPT descriptor for modifier -53 is: Due to extenuating circumstances or those that threaten the well-being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued.

Such circumstances include potentially life-threatening situations such as uncontrollable bleeding, hypotension, neurologic impairment or cardiac arrest. For example, a surgeon plans to repair an aneurysm in a patients abdomen (35081, direct repair of aneurysm, false aneurysm, or excision [partial or total] and graft insertion, with or without patch graft; for aneurysm, false aneurysm, and associated occlusive disease, abdominal aorta). While trying to access the aneurysm, however, the patient develops significant cardiac arrhythmia. Although the anesthesiologist works to control the PVCs, the surgical team decides to discontinue the procedure because of the potential risks to the patient. This procedure would be coded 35081-53, and the claim should be accompanied by the operative note as well as a cover letter, explaining why the procedure was discontinued and what percentage of the surgery actually was performed, Cobuzzi says.

Procedures also may be terminated for reasons that do not threaten the life or health of the patient. For example, if a 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]) is called off and rescheduled due to poor prep and the patient is asked to return the next day to try again, the procedure would be coded 45378-53 to indicate the service was discontinued.

In all instances other than colonoscopy, submitting a procedure with modifier -53 attached triggers an automatic review because carriers want to know how far the surgeon went in the procedure. The carrier then will pay a percentage based on that information. Because colonoscopy procedures have their own fee schedules, however, modifier -53 does not trigger a review for these services, Callaway-Stradley says.

Note: Modifier -53 should not be used under the following circumstances:

To report elective cancellation of a procedure prior to the patients anesthesia induction or surgical prep in the operating suite. For example, if the patient
decides not to go through with the procedure, modifier -53 cant be used.

In conjunction with any time-based code (e.g.,
anesthesiology and critical care codes).

With any code that already has the word limited
in its description.