Ob-Gyn Coding Alert

If the ob/gyn stops the procedure because it is endangering the welfare of the patient, append modifier -53 (discontinued procedure). But if he or she is not able to complete the procedure for other reasons, such as the anatomy of the patient, append modifier -52 (reduced services). Use a -52 for an incomplete procedure and a -53 for a canceled procedure, explains Susan Callaway-Stradley, CPC, an independent coding consultant who was recently named the American Association of Professional Coders coder of the year.

The distinguishing difference between modifiers -52 and -53 is that -52 reflects it was the ob/gyn who could not complete the procedure as it is outlined in the CPT, while -53 indicates the procedure was started but had to be stopped because the patient experienced unexpected responses.

Operative Report Directly Affects Pay-up

You shouldnt file an electronic claim for incomplete or canceled procedures, because the Health Care Financing Administration (HCFA) guidelines require payers to manually review all claims with modifiers -52 or -53 appended.

Therefore, detailed, accurate operative report documentation is extremely important when billing services with these modifiers, as reimbursement is directly assigned based on the procedure documentation. The payer calculates payment based on how much of the procedure was actually completed.

There is no set percentage of the allowable fee; it depends on what the report shows, and how the payer calculates reimbursement for that portion of the procedure that was completed, explains Callaway-Stradley.

It may be 50 percent. It may be less or it may be more, she says. For example, the patient may have crashed in the last five minutes [of a lengthy procedure], so you would be entitled to more than if it happened immediately after the procedure began.

The crucial element, reminds Callaway-Stradley, is to append the appropriate modifier. When you attach modifier
-53, the payer reviews the claim and operative report, looking specifically for dictation which supports or identifies the extenuating circumstances that threaten the well-being of the patient that required the procedure to be discontinued, she says. But if you use -53 and the documentation supports only that the procedure could not be completed, based on the CPT code description, then the payer will deny any payment for the claim as inappropriate use of modifier. In that case, you would have to resubmit an amended claim, showing modifier
-52, along with the report.

Note: Dont confuse modifiers -52 and -53 with modifiers -73 (procedure discontinued prior to the administration of anesthesia) and -74 (procedure discontinued after administration of anesthesia). Both sets of modifiers are used to indicate discontinued procedures; however, modifiers -73 and -74 should only be used in ambulatory surgery centers (ASC), not physician practices.

Reimbursement for Modifier -78

How much reimbursement will you receive by appending these modifiers? It varies, depending on the documentation and the carriers determination. Heres one rule you can count on: For modifier -78 (return to the operating room for a related procedure during the postoperative period), Medicare will reimburse no more than half of the intraoperative service, which is 69 percent of the total allowable. (Remember, for most carriers, reimbursement within the global period figures as 10 percent for pre-op, 69 percent for intra-op, and 21 percent for post-op.) So to estimate the maximum reimbursement for procedures appended with modifier -78, take 69 percent of the allowable and reduce it by half. However, dont put that figure on the claim form.

The insurance company will determine the reduced amount to be paid. Do not reduce your own fees. Otherwise, you may receive less than the reimbursement to which you are entitled, Callaway-Stradley advises.