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 method [separate procedure]) but can't obtain the biopsy because of a cervical stenosis. Instead, he stops the procedure and reschedules the patient to return for a dilation and curettage (58120, Dilation and curettage, diagnostic and/or therapeutic [nonobstetrical]).

In this case, you would report 58100 appended with modifier -52 and include the ob-gyn's documentation because it will frequently show significant work when he tried to accomplish the procedure even though it failed.

Significantly, the doctor did not terminate this service because of risks to the patient's health or well-being, but because of an anatomic problem, so modifier -52, not -53, would apply here.

Modifier -53 Means Stopped or Terminated

When you append a procedure code with modifier -53, you are telling the payer that the ob-gyn could not complete the procedure because the patient's health and well-being are at risk, says Carol Pohlig, BSN, RN, CPC, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia. CPT defines modifier -53 as a stopped or terminated procedure. This could be during surgery or when the patient is in the stirrups in your office.

Watch out: You can't use this modifier when the patient elects to cancel the procedure or service. In fact, CPT states that modifier -53 "is not used to report the elective cancellation of a procedure prior to the patient's anesthesia induction and/or surgical preparation in the operating suite."

For example, the ob-gyn is preparing to perform an open colpopexy (57280, Colpopexy, abdominal approach). The patient has been anesthetized, and the surgeon has made the initial incision when her blood pressure drops dramatically. The physician decides not to continue with the procedure and acts to regulate the patient's blood pressure. In this case, you would report 57280-53 to show that the doctor discontinued the surgery because of the patient's condition.

Not just for the OR: Some coders think that modifier -53 applies only to procedures performed in an operating room because of CPT's references to an operating suite. But this is not the case. CPT's definition states that you can use the modifier if the ob-gyn has induced anesthesia or performed the operative scrub or prep. You must prep a patient in the office for a surgical procedure just as you would in an operating room. Also, you may think that "anesthesia induction" only means general anesthesia, but this isn't so.

For instance, a patient presents with extensive vaginal lesions, and the ob-gyn decides to remove them in the office with cryosurgery (57065, Destruction of vaginal lesion[s]; extensive [e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery]). When he starts to work on the first lesion, the patient begins to bleed dramatically, and the physician decides to stop the procedure to address the bleeding. Here, you would report the services as 57065-53.

"Reporting terminated procedures with modifier -53 is imperative," Pohlig says. "When the procedure is rescheduled and performed at a later date, you will be less likely to receive a denial for frequency issues if the insurer has a record of the previously failed procedure. Of course, you may still be denied for frequency from those insurers that do not recognize modifier -53."

Remember: Don't confuse modifiers -52 and -53 with modifiers -73 (Discontinued outpatient procedure prior to anesthesia administration) and -74 (Discontinued outpatient procedure after anesthesia administration). Generally, hospitals or ambulatory surgery centers use modifiers -73 and -74 only for services and procedures performed for outpatients, Pohlig notes. The facility may still be able to capture revenue for its overhead costs, even if the procedure was not carried out. "Physicians should not report modifiers -73 and -74 on their claims, regardless of the place of service," she adds.