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, [...]