Neurology & Pain Management Coding Alert

An incomplete procedure doesn't have to equal zero reimbursement. And if you master modifiers 52 (Reduced services) and 53 (Discontinued procedure), you can reap the rewards.

Many coders get confused between modifiers 52 and 53. But the difference doesn't have to stump you, according to Carol Pohlig, a senior coding and education specialist with the University of Pennsylvania in Philadelphia.

Rely on modifier 52 for an "elective" situation. In other words, your physician chooses not to go any further with the procedure because the procedure has already achieved its objective, Pohlig says. The physician might also end the procedure because he has gathered all the needed information -- there's no medical reason to not continue with the procedure, but there's also no medical reason to continue.

Example 1: A CPT code calls for a procedure to be performed over a 24-hour period, but the physician only spends 12 hours on it, says Dianne Wilkinson, compliance officer and quality manager with MedSouth Healthcare in Dyersburg, Tenn.

Example 2: You can also report modifier 52 when your physician's documentation shows that he didn't complete all the work a code represents. These situations can come into play with sleep studies or prolonged EEG monitoring sessions that are shorter than your neurologist originally planned.

Warning: Don't use modifier 52 when your physician performs cases that don't have individual CPT codes, Pohlig says. Some coders might be tempted to append modifier 52 to an existing code if the procedure is similar to a portion of an existing procedure code. But CPT rules require you to report an unlisted-procedure code instead, such as 95999 (Unlisted neurological or neuromuscular diagnostic procedure).

53 Represents Discontinued Procedure

Modifier 53 (Discontinued procedure) is for situations when the physician sees some risk that could threaten the patient's health if the procedure continues, says Barbara J. Johnson, CPC, MPC, owner of Real Code Inc. in Moreno Valley, Calif. You can report modifier 53 with either diagnostic or therapeutic procedures in a hospital setting.

Example: Your neurologist schedules a diagnostic lumbar puncture for Mrs. Brown (62270, Spinal puncture, lumbar, diagnostic). He begins the procedure but discontinues it because of complications. You-ll report 62270 with modifier 53.

In an outpatient facility setting, you use a separate set of modifiers for discontinued and incomplete procedures, Pohlig says: 73 (Discontinued outpatient procedure prior to anesthesia administration) and 74 (Discontinued outpatient procedure after anesthesia administration). Report these modifiers based on whether your neurologist stopped the procedure before or after the patient received anesthesia.

Note: You can submit modifier 73 for discontinued cases before anesthesia administration, but that doesn't apply to modifiers 52 and 53. You can only report modifiers 52 or 53 if the physician began the procedure -- including anesthesia administration.

Consider this: What if the patient receives anesthesia but your neurologist stops the case before actually doing anything? You can't report the case, unless your physician also acts as the anesthesiologist. You should only bill for the procedure if your physician starts performing his part.

In the past, Pohlig says, she recommended that claims with modifiers 52 or 53 should "drop to paper" so you could submit a written explanation with the claim. But in the age of HIPAA and electronic standards, you must bill electronically first.

Once you bill electronically with either modifier 52 or 53, Pohlig says, the carrier will request more information. "If your physician is documenting properly, the operative note should contain all the information the carrier needs," she says.

"If you had a failed procedure, the op note should state why and what failed," says Lisa Center, quality review coordinator for the Freeman Health Center in Joplin, Kan. And if your neurologist discontinued the procedure due to the patient's condition, the op note should detail what factors prevented the procedure from going forward.

Take care of it: If you do feel the need to include a cover letter explaining why the procedure didn't continue, Pohlig recommends that your physician write the letter himself because he knows the details.

If your patient had an adverse response to anesthesia (including vomiting or nausea), include your nurse's report on these symptoms, says Maxine Lewis with Medical Coding Reimbursement Management in Cincinnati.

Important: Make sure your cover letter or documentation spells out exactly how far the physician progressed with the procedure. Don't leave it to the carrier to decide how much reimbursement you-re owed, Lewis adds.