General Surgery Coding Alert

Question: If one of our surgeons stops in the middle of diagnostic testing, or even a minor procedure, because the patient is uncooperative, may we still bill for the service?

Delaware Subscriber Answer: Yes, you may still file a claim, but depending on the exact circumstances, you may have to append either modifier -52 (Reduced services) or -53 (Discontinued procedure) to the appropriate CPT procedure code.
 
Modifier -52 applies when "a service or procedure is partially reduced or eliminated at the physician's discretion," according to Appendix A of CPT ("Modifiers"). You should append modifier -53 if the physician elects to terminate a surgical or diagnostic procedure "due to extenuating circumstances or those that threaten the well-being of the patient," according to CPT instructions.
 
In practice, there's enough overlap between modifiers -52 and -53 to cause continued confusion on how to apply them (see the graph below for guidance). Generally, if the patient or physician plans or expects a reduction in services, or if the patient or physician electively cancels the procedure, modifier -52 is appropriate. For example, if a descriptor specifies a bilateral procedure but no code describes an equivalent unilateral procedure, and the physician provides the service on one side of the body only, modifier -52 is appropriate. In such a case, you must be certain that there is not a designated CPT code to describe the "lesser" procedure.
 
In contrast, if the physician reduces the service due to unexpected complications that place the patient at unacceptable risk, modifier -53 is appropriate. That is, the physician intended to provide the complete service but - due to unusual or extenuating circumstances - was unable to do so. For example, a physician providing a surgical service may abandon the procedure due to extensive hemorrhaging or adverse reaction to anesthesia. In your case, the physician elected to stop the service because of an uncooperative recipient, not because of any undue risk of harm to the patient. Therefore, modifier -52 is more appropriate.
 
When appending either modifier, provide documentation with the claim explaining the reason the service was reduced or terminated. Do not reduce your fee: Allow the payer to make a reimbursement decision based on documentation.

- Technical and coding advice for You Be the Coder and Reader Questions provided by Marcella Bucknam, CPC, CCS-P, CPC-H, CCA, HIM program coordinator at Clarkson College in Omaha, Neb.