Ophthalmology and Optometry Coding Alert

Question: How should I decide between modifiers 52 and 53?

Pennsylvania Subscriber

Answer: Modifier 52 (Reduced services) applies when "a service or procedure is partially reduced or eliminated at the physician's discretion," according to CPT's Appendix A, "Modifiers."
 
Alternatively: You should append modifier 53 (Discontinued procedure) if the physician elects to terminate a surgical or diagnostic procedure "due to extenuating circumstances or those that threaten the well-being of the patient," according to CPT instructions.
 
In practice, there's enough overlap between modifiers 52 and 53 to cause continued confusion on how to apply them. Generally, however, if the patient or physician plans or expects a reduction in services, or if the patient or physician electively cancels the procedure, modifier 52 is appropriate.
 
Example: If a descriptor specifies a bilateral procedure but no code describes an equivalent unilateral procedure, and the ophthalmologist provides the service on one eye only, modifier 52 is appropriate. In such a case, you must be certain that there is no designated CPT code to describe the lesser procedure.
 
In contrast, if the ophthalmologist reduces the service due to unexpected complications that place the patient at unacceptable risk, modifier 53 is appropriate. That is, the physician intended to provide the complete service but -- because of unusual or extenuating circumstances -- was unable to do so.
 
For example, an ophthalmologist providing a surgical service may abandon the procedure due to extensive hemorrhaging or adverse reaction to anesthesia. In your case, the physician elected to stop the service because of an uncooperative recipient, not because of any undue risk of harm to the patient. Therefore, modifier 52 is more appropriate than 53.
 
Pointer: Another way to tell if the service needs a 52 or a 53 would be to consider if the patient had the entire service the physician intended to provide.
 
Use modifier 53 if the surgeon discontinued the procedure without completing the treatment as planned. Use modifier 52 if the service is complete. Although not foolproof, this method is very consistent in identifying which modifier to use.
 
When appending either modifier, provide documentation with the claim explaining the reason your ophthalmologist reduced or terminated the service. Do not reduce your fee. Instead, allow the payer to make a reimbursement decision based on documentation. Documentation should also contain an estimation of the total percent of the procedure that the ophthalmologist performed and completed.