Neurology & Pain Management Coding Alert

Knowing whether the physician halted the procedure by choice or necessity makes the difference for modifier -52/-53

When neurologist provides a less-than-"total" service, you must rely on modifiers -52 and -53 to describe the situation accurately. If you're looking for ways to distinguish between these modifiers, you need only ask yourself, "Why did the physician stop the procedure?"

For Planned or Electively Reduced Procedures, Choose -52

When the neurologist plans or expects a reduction in the service, or if the neurologist 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 physician must have reduced the services by choice rather than by necessity. "For example, the neurologist 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: Code 95925 describes short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in upper limbs, while 95926 describes the same service in the lower limbs. Notice the use of the plural "limbs" in these descriptors: The codes refer to bilateral studies. Therefore, if the neurologist provides a unilateral study only, he has provided a reduced service. Therefore, you are correct to append modifier -52 to 95925 or 95926, as appropriate.

Example B: Sleep studies and polysomnography (95805-95811) include six or more hours of monitoring and recording, according to CPT guidelines. In those cases when the neurologist (or technician) records fewer than six hours of sleep activity, you must indicate reduced services by appending modifier -52 to the appropriate sleep study/polysomnography code.

Example C: During electromyographic testing (for example, 51784, Electromyography studies of anal or urethral sphincter, other than needle, any technique), the patient becomes uncooperative and refuses to continue with the procedure. In this case, there is no medical reason that the neurologist cannot complete the testing (the patient's health is not at risk), but she elects to halt the procedure rather than proceed against the patient's wishes. Once again in this case, you should append -52 to 51784 to indicate a reduced service.

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 apply modifier -53 if the patient or physician electively cancels a procedure prior to the administration of anesthesia or surgical preparation in the operating room, CPT guidelines state. 

Modifier -53 (Discontinued procedure) -- Under certain circumstances, the physician may elect to terminate a surgical or diagnostic procedure. 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. This circumstance may be reported by adding the modifier '53' to the code ... for the discontinued procedure (CPT 2004, Appendix A).
 
"Modifier -53 describes an 'unexpected problem,' beyond the physician's or patient's control, that necessitates the termination of the procedure," says Carol Pohlig, BSN, RN, CPC, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia. "The physician doesn't so much elect to discontinue the procedure as he or she is forced to do so." Typically, the discontinued procedure will provide no benefit to the patient.

Example D: A common use of modifier -53 involves lumbar puncture (for instance, 62272, Spinal puncture, therapeutic, for drainage of cerebrospinal fluid [by needle or catheter]). Following anesthesia and preparation, the neurologist attempts the spinal tap but the patient becomes unstable (for instance, he may have a blood pressure spike or cardiac arrythmia). The neurologist abandons the procedure to avoid risking the patient's health. You should report such a procedure as 62272-53.

Take note, however, that if the patient gets "cold feet" and refuses to undergo the procedure prior to the administration of anesthesia, you should apply modifier -52 -- rather than -53 -- to 62272.

Example E: The neurologist must abandon a laryngeal electromyography because the patient has a rapid increase in pulse and develops shortness of breath and other symptoms. Report 95868 (Needle electromyography; cranial nerve supplied muscle[s], bilateral) with modifier -53 appended.