"Just because you cant complete a procedure, doesnt mean you cant get paid for it. Understanding the meaning of modifiers -52 (reduced services) and -53 (discontinued procedure) can help
ob-gyn practices obtain reimbursement dollars rightfully owed to them when procedures are unsuccessful, abandoned, or just go wrong.
Confusion over modifiers -52 and -53 arises when coders, physicians, and even payers fail to carefully read and understand the CPT Appendix A in which the modifiers are described.
People are not reading what the book says, and then dont interpret it correctly, says Melanie Witt, RN, CPC, MA, program manager in the department of coding and nomenclature at the American College of Obstetricians and Gynecologists (ACOG) in Washington, DC. Further complicating modifier use, she adds, are insurance companies and other payers that dont keep track of changes in CPT, and fail to program their computerized claims systems to recognize some or all modifiers. Sometimes they just flatly refuse to accept them.
So, how can ob-gyns get paid when they perform a procedure that turns out to be incomplete? The answer, experts say, is to properly code what services were actually rendered, and be sure to document them well, because they may be reviewed manually. Exactly how much of a service has been reduced or discontinued varies with every patient, so some claims processing systems cannot automatically process claims with -52 or -53 modifiers. Plus, guidelines issued by the Baltimore-based Health Care Financing Administration (HCFA), the department which manages Medicare, require payers to manually review all claims with modifiers -52 and -53.
Understanding Modifier -53 Key to Getting Paid
Cindy Parman, CPC, CPC-H, principal and co-founder of Coding Strategies Inc., in Dallas, GA, a coding and reimbursement consulting firm, explains that modifier -53 indicates the physician could not complete the procedure because the patient had a problem. The CPT clearly defines -53 as a stopped or terminated service, adds Witt. Discontinued means stopped, whether the patient was in surgery or whether you had her in the stirrups in your office. Its when everything comes to a grinding halt and nothing else is done to that patient, Witt describes.
Modifier -53 is for circumstances in which a diagnostic or surgical procedure is terminated because of circumstances that threaten the well-being of the patient, she emphasizes. This isnt for the patient who says half way through the procedure, Oops, I dont want to do this
now. There has to be a situation affecting the well-being of the patient, for example, her blood pressure dropped or she started bleeding dramatically, so you had to stop, Witt says.
A common mistake coders and ob-gyns make involving modifier -53 is they think it only [...]
