Orthopedic Coding Alert

Some orthopedic surgery coders have difficulty distinguishing between modifiers -52 (reduced services) and -53 (discontinued procedure). The CPT descriptors for both are similar. There are, however, significant differences between these two modifiers, and by following two guidelines, coders can keep them straight.

Guideline 1: Modifier -52 should be attached to codes when the surgeon completed the procedure but did not fulfill all of its requirements.

Guideline 2: Modifier -53 should be used for
procedures that are terminated by the surgeon, typically
because of the patients condition.

For example, when an orthopedic surgeon attempts to perform a revision of total hip arthroplasty, both components, with or without autograft or allograft (27134), but instead replaces the entire acetabular and femoral components and replaces the femoral component and the acetabular liner, modifier -52 appended to 27134 shows the payer that a reduced service was performed.

Modifier -52 is not used for a discontinued procedure, but rather when the physician completed what he or she set out to do but did so performing less than the complete procedure. If the surgeon, for instance, only performed four of six components of the procedure, reporting it without a -52 modifier would be inappropriate, says Barbara J. Cobuzzi, MBA, CPC, president of Cash Flow Solutions, a medical billing and coding consulting firm in Lakewood, N.J. If you dont do exactly what the code describes, you need to inform the carrier that you didnt do it, which is what modifier -52 does.

Modifier -52 is also used for procedures that have no established CPT code. A physician may be inclined to use an analog code, for example, when a claviculectomy is done with a scope rather than as an open procedure. The code would then be 23125-52, (claviculectomy; total; -reduced services). But Susan Callaway-Stradley, CPC, CCS-P, an independent coding consultant and educator in North Augusta, S.C., points out that most carriers prefer unlisted codes to analog codes, in which case 23929-52, (unlisted procedure, shoulder,-reduced services) would be the appropriate code. In either case, documentation should describe the procedure and support the claim. If CPT, Medicare or private carriers instruct the use of an unlisted code, attaching modifier -52 to a more complex procedure in this manner would be inappropriate, she says.

When submitting claims with a modifier -52, Cobuzzi recommends that coders bill the procedure at the full fee and include a cover letter that explains what wasnt done and why. If possible, she adds, the percentage of the full procedure that was performed should be indicated to assist the payer in determining how much to reduce the fee.

Unfortunately, physician practices have to leave it up to the payer to set the fee, Cobuzzi says. She notes that if a percentage is taken off the full fee, the carrier may reduce reimbursement by a further percentage.

Modifier -53 Will Trigger a Review

Because of extenuating circumstances or those that threaten the well-being of the patient, a surgical or diagnostic procedure may be started but discontinued.

Such circumstances include potentially life-threatening situations such as uncontrollable bleeding, hypertension, neurologic impairment or cardiac arrest. For example, a surgeon is operating on an auto-accident victim with multiple trauma and plans to repair a complex acetabular fracture (27228, open treatment of acetabular fracture[s] involving anterior and posterior [two] columns, includes T-fracture and both column fracture with complete articular detachment, or single column or transverse fracture with associated acetabular fracture, with internal fixation). But, after the procedure has commenced, the patient develops significant cardiac arrhythmia. Although the anesthesiologist works to control the patients vital signs, the surgical team decides to discontinue the procedure because of the potential risks to the patient. This procedure would be coded 27228-53, and the claim should be accompanied by the operative note as well as a cover letter explaining why the procedure was discontinued and what percentage of the surgery was performed.

Procedures may also be terminated for reasons other than those that pose a risk to the life or health of the patient. For example, if a total hip arthroplasty (27130, arthroplasty, acetabular and proximal femoral prosthetic replacement [total hip replacement], with or without autograft or allograft) is called off and rescheduled because an open ulceration on the patients lower leg was discovered during the surgical prep, the procedure would be coded 27130-53 to indicate the service was discontinued.

In almost every instance, submitting a procedure with modifier -53 attached triggers an automatic review because carriers want to know how far the surgeon went with the procedure. The carrier then will pay a percentage based on that information.

Note: Modifier -53 should not be used under the following circumstances:

To report elective cancellation of a procedure prior to
the patients anesthesia induction or surgical prep in the operating suite. For example, if the patient decides not
to go through with the procedure.

In conjunction with any time-based code (e.g., anesthesi-
ology and critical care codes).

With any code that already has the word limited in its description.