Ob-Gyn Coding Alert

File preparation and clear documentation are the keys to getting these claims paid

When you're reporting codes appended with modifiers -52 (Reduced services) and -53 (Discontinued procedure), use these quick methods from coding experts to help ensure your claims will be paid.
 
1. Prepare for modifier -53 claim denials. Because modifier -53 and some modifier -52 claims involve varying circumstances, payers' systems generally will kick them out, and they will review them manually. HIPAA, however, requires that you file all claims electronically, says Carol Pohlig, BSN, RN, CPC, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia. Unfortunately, you will have to wait for the denial and/or "request for additional information" from the insurer before you can send in your documentation.

Have the copies ready in a separate file when you submit the claim, knowing that the carrier will deny the claim or request further information, Pohlig suggests. "Collecting this data in advance may be more efficient than handling this at the time the rejection is received, especially if the chart is unavailable." Be sure to check with your carriers to determine their needs.

2. Provide detailed, accurate and easily understandable documentation. Insurers commonly review codes appended with modifier -53 manually, but the reviewer will likely not be a clinician. Consequently, your documentation should be put in terms a layperson can understand. You may want to include a special summary report that describes the patient's condition, what the planned procedure was, what the extenuating circumstances were, what actually happened because of the patient's condition, and what time and effort was involved. This summary shouldn't be more than a few paragraphs, with the first paragraph detailing the procedure's medical necessity and the second noting what was planned and why it was discontinued.

For modifier -52, be sure the ob-gyn dictates in the operative note how much of the service or procedure that  he had planned to render was actually completed and do so in terms of a percentage. This will give the carrier a guide regarding what would be appropriate reimbursement, especially if the physician reduced the service. Otherwise, this determination -- and your payment -- may be left entirely to the payer.

3. Document, document, document. Ob-gyns may  often hesitate to document mistakes, such as puncturing a colon during a gynecologic laparoscopic procedure, because they may fear a malpractice lawsuit. But explicit documentation, involving the reason for termination as well as the interventions provided to stabilize and/or resolve the condition, can help to reduce the medico-legal risk and help ensure appropriate reimbursement when extenuating circumstances occur -- which is often the case when you're reporting modifiers -52 and -53, Pohlig says. Everything has to be recorded so you can justify reporting the modifiers and ensure proper reimbursement for the work performed.

"Your documentation is a legal document that is used to describe the procedures performed, as well as any circumstances that may arise," says Lynn M. Anderanin, CPC, senior coding consultant for Health Info Services in Des Plaines, Ill. "Not documenting circumstances is considered fraud."

4. Don't confuse reduced services with reduced charges. You shouldn't reduce your fees when filing a claim with modifier -52. Payers will often see the modifier and automatically reduce the reported fee. So if you've already reduced it, the insurer will probably further discount the fee. The documentation you provide will help the carrier determine the appropriate reduction. If you're not sure exactly how to bill, contact the payer and ask for help.