Neurosurgery Coding Alert

Knowing why your surgeon halted the procedure matters for modifiers -52/-53

When a surgeon provides a less-than-total service (by choice or necessity), you can quickly decide between modifiers -52 and -53 to describe the situation by asking yourself, "Why did the physician stop the procedure?"

When 1.) the neurosurgeon plans or expects a reduction in the service, or 2.) if the neurosurgeon 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 reduction of services must have occurred by choice (either the surgeon's or the patient's) rather than necessity.

"For example, the surgeon 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," explains 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: The patient has a basal cell carcinoma of the scalp that extends to the skull. If the procedure required limited or partial excision of the outer table of the skull, you would report 61500 (Craniectomy; with excision of tumor or other bone lesion of skull) and append modifier -52 because the craniectomy code assumes a full thickness procedure.

In contrast, if the tumor invaded full thickness through the skull, you could report 61500 without a modifier.

Example B: Asurgeon re-opens a previous craniotomy incision and removes the skull flap for evacuation of hematoma, after excision of brain tumor through the same craniotomy the previous day. Because such a procedure may require significantly less effort (and therefore qualifies as a reduced service), you should apply modifier -52 to the hematoma evacuation code (61312, Craniectomy or craniotomy for evacuation of hematoma, supratentorial; extradural or subdural).

In the case 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 CPTcode. You should not apply modifier -53 if the surgeon or patient electively cancels a procedure prior to the administration of anesthesia or surgical preparation in the operating room, according to CPTguidelines.

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 reported by the physician 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," explains 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."

Example C: You might commonly use modifier -53 during lumbar puncture (for instance, 62272, Spinal puncture, therapeutic, for drainage of spinal fluid [by needle or catheter]). Following anesthesia and preparation, the neurosurgeon attempts the spinal tap but the patient becomes unstable (for instance, he may experience a blood pressure spike or cardiac arrythmia). The surgeon abandons the procedure so as not to place the patient's health at risk. You should report 62272-53.

Example D: While the surgeon attempts to access an aneurysm, the patient develops significant cardiac arrhythmia. Although the anesthesiologist works to control the premature ventricular contractions, the surgical team decides to discontinue the procedure because of the potential risks to the patient. In this case you should report 61700 (Surgery of simple intracranial aneurysm, intracranial approach; carotid circulation) with modifier -53.