Neurology & Pain Management Coding Alert

Question: If I stop testing (electroencephalography, electromyography, magnetic resonance imaging, etc.) because the patient is uncooperative, may I 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 modifier -52 (Reduced services) or -53 (Discontinued procedure) to the appropriate CPTprocedure code.

Referencing modifier -52, Appendix A ("Modifiers") of CPT specifies, "Under certain circumstances a service or procedure is partially reduced or eliminated at the physician's discretion." Meanwhile, it explains the application of modifier -53 by stating, "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."

In practice, there's enough overlap between modifiers -52 and -53 to cause continued confusion regarding how to apply them (see graph, next page). Generally, if the reduction in services is planned or expected, or electively canceled by the patient or physician, modifier -52 is appropriate. For example, if a descriptor specifies a bilateral procedure with no code to describe 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 no designated CPTcode to describe the "lesser" procedure.

By 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 extenuating circumstances, could not 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 physician reduced or terminated the service. Do not reduce your fee. Allow the payer to make a reimbursement decision based on documentation.

Clinical and coding expertise for You Be the Coder and Reader Questions provided by Neil Busis, MD, chief of the division of neurology and director of the neurodiagnostic laboratory at the University of Pittsburgh Medical Center at Shadyside, and clinical associate professor in the department of neurology, University of Pittsburgh School of Medicine; and 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.