Neurosurgery Coding Alert

Some neurosurgery coders have problems distinguishing between modifiers -52 (reduced services) and -53 (discontinued procedure), in part because their CPT descriptors are similar in many ways. A simple guideline can help coders who choose to use -52 and -53: Modifier
-52 should be attached to codes when the neurosurgeon completed the procedure but did not fulfill all of its requirements, and modifier -53 should be used for procedures that are terminated by the neurosurgeon, typically because of the patients condition.

When to Use Modifier -52

Modifier -52 is not used for an incomplete procedure but rather when the physician completed what he or she set out to do but did so while performing less than all of the complete procedures possible components. If the neurosurgeon, for instance, only performed four of six components of a given procedure, reporting it without a
-52 modifier would be inappropriate, says Barbara Cobuzzi, MBA, CPC, CCS-P, a coding and reimbursement specialist in Lakewood, N.J.

If you dont do exactly what the code describes, you need to inform the carrier that you didnt do it, which is what modifier -52 does, she says.

For example, a patient has a basal cell carcinoma of the scalp that extends down to the skull. If the procedure required limited or partial excision of the outer table of the skull, the neurosurgeon might use 61500-52 (craniectomy; with excision of tumor or other bone lesion of skull), whereas if the tumor invaded full thickness through the skull, code 61500 would be billed without a modifier.

What about procedures that have no established CPT code? In certain situations, instead of using an unlisted procedure code, neurosurgeons may prefer to use the code of a similar, but more encompassing listed procedure and attach modifier -52 to it, Cobuzzi says.

The CPT range for neurosurgery coders does not always offer all the codes needed to describe the services the neurosurgeons perform these days, states Rhonda Petruziello, CPC, reimbursement specialist for Neurosurgery at the Cleveland Clinic Foundation. Modifiers such as -52 can help further enhance or reduce your codes appropriately.

Frequently, informs Petruziello, when we use 64999 (unlisted procedure, nervous system), the carrier will call us to determine the CPT code that comes closest to the procedure performed. A modifier such as -52 appended to the CPT code that best describes the service, will help carriers attach a value to the service where that is not possible when billing for unspecified codes (64999).

Sometimes CPT, Medicare or a private carrier will instruct the provider to use an unlisted code, in which case attaching modifier -52 to a more complex procedure would be inappropriate, says Susan Callaway-Stradley, CPC, CCS-P, an independent coding consultant and educator in North Augusta, S.C. Anytime modifier -52 is billed out, make sure the documentation supports the claim. Many carriers want to see the documentation before they consider reimbursing procedures with modifier -52 attached, Callaway-Stradley adds.

When submitting claims with modifier -52 attached, Cobuzzi recommends that the procedure be billed out at the full fee and include a simple cover letter that explains what wasnt done and why. If possible, she adds, the percentage of the full procedure that was performed should be indicated to assist the payer in determining how much to reduce the fee.

Unfortunately, you have to leave it up to the payer to set the fee, Cobuzzi says, noting that if you take your own percentage off the full fee, the carrier may reduce your reimbursement by a further percentage of that.

When to Use Modifier -53

The key phrase in the CPT descriptor for modifier -53 is: 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.

Such circumstances include potentially life-threatening situations such as uncontrollable bleeding, hypotension, neurologic impairment or cardiac arrest. For example, a surgeon plans to repair an aneurysm (61700, surgery of intracranial aneurysm, intracranial approach; carotid circulation). While trying to access the aneurysm, however, the patient develops significant cardiac arrhythmia. Although the anesthesiologist works to control the premature ventricular contractions, the surgical team decides to discontinue (and possibly reschedule) the procedure because of the potential risks to the patient. This procedure would be coded 61700-53, and the claim should be accompanied by the operative note as well as a cover letter, explaining why the procedure was discontinued and what percentage of the surgery actually was performed, Cobuzzi says.

Procedures also may be terminated for reasons that do not threaten the life or health of the patient. For example, if a gamma knife surgery (61793, stereotactic radiosurgery [particle beam, gamma ray or linear accelerator], one or more sessions) is called off and rescheduled because the patient is not physically able to continue with the procedure (i.e., a patient is responding adversely to the procedure itself), the procedure would be coded 61793-53 to indicate the service was discontinued.

The most time consuming aspect of that procedure, says Petruziello, is the planning that precedes it (61795, stereotactic computer assisted volumetric [navigational] procedure, intracranial, extracranial, or spinal [list separately in addition to code for primary procedure]).

Regardless of whether 61793 was performed, the computerized planning (61795) should be billed in full because that part of the service was completed.

You cannot use modifier -53 if the patient elects to cancel the procedure prior to anesthesia induction or surgical preparation in the operating suite. Nor should you use modifier -53 if the surgery is stopped for the neurosurgeons convenience or necessity, such as if the neurosurgeon is called away to another emergency.

Experts Disagree

Some neurosurgical coding experts advise against using these modifiers altogether. Richard Bucholz, MD, associate director of neurosurgery at St. Louis University Hospital, for example, admonishes using -52 with any regularity, if at all. Downgrading a large, complex code with a modifier such as -52, he says, is likely to raise more red flags than upgrading a code that is smaller in scope.

Neurosurgical codes are tightly written, says Bucholz. Because many procedures have separate codes for approach, technique and repair, it makes it difficult to justify modifying them in this way.

For example, if you appended modifier -52 to 62147 (cranioplasty with autograft [includes obtaining bone grafts]; larger than five centimeters in diameter) it would be considered inappropriate to describe a procedure that was smaller than five centimeters because code 62146 already exists to denote five centimeters or less.

Modifier -53 is another one that should be used sparingly, if at all, according to Bucholz. Frequent use of the modifier may result in audits, he says, because these modifiers should be used only for procedures involving unusual circumstances. Carriers do not expect to see them used on a regular basis, and red flags are raised when they are used routinely.