Otolaryngology Coding Alert

Here’s how to handle a provider-planned reduction in service.

When your otolaryngologist has to stop a surgery before completing the procedure, their efforts don’t have to be a total loss. But managing the claim to get the pay you deserve depends on deploying one of two modifiers based on the details of the case.

Read on to get our experts’ advice about how to choose the correct modifier: 52 (Reduced services) or 53 (Discontinued procedure).

Surgeon’s Judgement Marks Modifier 52 Claims

“Modifier 52 indicates that a service was partially reduced or eliminated at a physician’s discretion,” explains Mary I. Falbo, MBA, CPC, CEO of Millennium Healthcare Consulting Inc. in Lansdale, Pennsylvania.

If a provider plans or expects a reduction in the service, or electively cancels the procedure prior to completion, you should append modifier 52 to the appropriate CPT^® code. Per Appendix A in the CPT^® manual: “Under certain circumstances a service or procedure is partially reduced or eliminated at the physician’s discretion. Under these circumstances the service provided can be identified by its usual procedure code and the addition of the modifier ‘52,’ signifying that the service is reduced.”

For instance: Modifier 52 may reflect that the surgeon performed a bilateral procedure, but intentionally addressed only one side.

Example: “This would be the case when performing an audiology service for a patient that is deaf on one side; specifically, the provider would be measuring the patient’s hearing on the non-deaf ear,” says Barbara J. Cobuzzi, MBA, CPC, COC, CPC-P, CPC-I, CENTC, CPCO, of CRN Healthcare in Tinton Falls, New Jersey. “Since audiometric services are bilateral, the full service is not being completed case. In these instances, you may append modifier 52 to the audiologic service. But if the code descriptor states ‘unilateral,’ you shouldn’t use modifier 52 in this way,” advises Cobuzzi.

Another way you might employ modifier 52 is when the physician doesn’t perform all the components of the procedure, says Marcella Bucknam, CPC, CCS-P, COC, CCS, CPC-P, CPC-I, CCC, COBGC, revenue cycle analyst with Klickitat Valley Health in Goldendale, Washington. “The most frequent use that I’ve seen is when a patient has surgery and the surgeon does not close the wound, either because the wound is going to be allowed to heal by secondary intent or because they are planning to bring the patient back to the OR [operating room] and do another procedure and then close the wound at that time,” she explains.

Trio of Circumstances Defines Modifier 53 Claims

Cases that require modifier 53 are different than those described above that warrant using modifier 52. With a couple of exceptions, the surgeon must fulfill one of three specific circumstances for you to use modifier 53, Bucknam explains:

• After anesthesia was induced, the patient developed a complication that required the procedure to be stopped for the wellbeing of the patient— for example, due to a drop in blood pressure.
• After anesthesia was induced, the physician developed a problem and could not go on. I’ve only seen this one time, when the surgeon cut his hand during the procedure.
• After anesthesia was induced, it was discovered that a key piece of equipment was not working correctly and the procedure could not be continued.

These stops in services are usually termed “unexpected” or “due to risk” cancellations. Again, per Appendix A in CPT^® 2021: “Under certain circumstances, the physician may elect to terminate a surgical or diagnostic procedure. Due to extenuating circumstances or those that threaten the wellbeing of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued. This circumstance may be reported by adding the modifier ‘53’ to the code reported by the physician for the discontinued procedure.”

Follow This Documentation Template on 52/53

According to Falbo, the Centers for Medicare & Medicaid Services (CMS) calls for the following documentation on modifier 52/53 claims:

• A brief explanation for the reduction and/or discontin­uation of service
• Complete documentation of the reason for reduction retained in the patient’s record
• Procedure start time
• Procedure stop time
• Explanation as to why the procedure was discontinued
• An estimate of the percentage of the procedure that was performed.

Even though the documentation template seems straight forward, you can’t assume that the surgeon provided all the relevant information to warrant using modifier 52 or 53.

“Usually the documentation is self-evident: only one side was done on a bilateral procedure; the procedure had to be stopped because the patient’s heartbeat was irregular; the abdomen was not closed after a procedure was performed, etc. However, the coder should be careful to verify that the documentation is complete. I’ve seen situations where the surgeon got interrupted during his dictation and didn’t state he had closed the abdomen or treated the other side. That required an amendment, not a modifier,” says Bucknam. “Typically, if that decision is made the surgeon will document that the wound was covered and would be allowed to heal by secondary intent or that the patient would be returning to the OR … to make it clear that the documentation is complete.”

Indicate the percentage of the procedure that was completed and a brief description of why in box 19 of the claim form. This should inform the insurance payer how much of the CPT^® code was completed for payment of the claim.