General Surgery Coding Alert

Question: My doctor attempted placing a central line on the left side. This was not successful. He then switched to the right side. Would you code the first attempt with a modifier 52 or modifier 53?

New York Subscriber

Answer: The exact right coding for the failed attempt might depend on the documentation.

Option 1: First, consider using modifier 52 (Reduced services) on the first attempt (left side) for the central line placement.

Option 2: Or, consider adding a modifier 22 (Increased procedural services) to the right side placement to capture payment for the additional work involved since the physician attempted the left-side placement first. Physicians often spend more time on abandoned efforts than they ever do on the ones that go well, so you should try to get reimbursement for it.

Important: You should not use modifier 53 (Discontinued procedure) because you can only use modifier 53 if the procedure has to be abandoned due to one of three circumstances:

• A patient health issue

• An equipment failure

• The surgeon cannot continue (for example, if the surgeon cut his hand).