Ob-Gyn Coding Alert

Experts explain what to do when the ob-gyn doesn't complete the procedure The ob-gyn performs a total abdominal hysterectomy, but decides not to do the partial vagin-ectomy. How should you code for this? The answer: Ask why he stopped the procedure.

When the ob-gyn can't complete a procedure, many ob-gyn coders are confused about when to use modifier -52 (Reduced services) and when to use modifier -53 (Discontinued procedure). But once you know why the physician decided not to finish the surgery or service, you can readily pick your modifier.

Avoid this problem: Another key to getting reimbursed when the ob-gyn performs a procedure is to properly code for the services the physician actually performed. You should be sure that the procedures are documented well because the carrier may review them manually. Exactly how much a service was reduced varies with each patient, so some claims-processing systems cannot automatically recognize and process codes appended with modifiers -52 and -53. And, CMS requires payers to manually review all claims with these modifiers.

"It is important to use the code that most clearly defines the procedure," says Lynn M. Anderanin, CPC, senior coding consultant for Health Info Services in Des Plaines, Ill. Make sure another code(s) doesn't better describe the procedure(s) the ob-gyn performed before you use modifier -52, she adds.

Use -52 in Two Situations Modifier -52 has two functions: to indicate a reduced service or a failed procedure. For example, if an ob-gyn performs a total abdominal hysterectomy but doesn't do the procedure's vaginectomy portion, then you should report 58200 (Total abdominal hysterectomy, including partial vaginectomy, with para-aortic and pelvic lymph node sampling, with or without removal of tube[s], with or without removal of ovary[s]) with modifier -52. In this situation, the modifier means that the surgeon elected not to perform a portion of the procedure that the CPT code definition describes. But that code is still the best one to report.

Global ob: You can also append modifier -52 to a global obstetric code (for example, 59400, Routine obstetric care including antepartum care, vaginal delivery [with or without episiotomy, and/or forceps] and postpartum care) if, for instance, the ob-gyn saw the patient six times but was the only physician to care for her pregnancy and did the delivery and postpartum care. Because the global package usually includes 13 visits and the ob-gyn only provided six, adding modifier -52 tells the payer that the physician didn't provide all the care included in the service package as CPT describes.

Modifier -52 also comes in handy when the ob-gyn has a failed procedure. For example, the physician is trying to perform an endometrial biopsy (58100, Endometrial sampling [biopsy] with or without endocervical sampling [biopsy], without cervical dilation, any [...]