Otolaryngology Coding Alert

Question: How do we know if an -unsuccessful- procedure is reduced or discontinued?

For instance, the ENT attempted cerumen removal (69210), but the child screamed and cried so much that the mother asked the physician to stop. The visit was only for scheduled routine cerumen removal because the boy's hearing aids cause impacted cerumen. Is modifier 52 or 53 correct in this case?


Montana Subscriber

Answer: You should apply modifier 52 when -a service or procedure is partially reduced or eliminated at the physician's discretion,- according to CPT's Appendix A, -Modifiers.- In contrast, you should append modifier 53 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 (see the graph on page 32 for guidance).

Generally, if the patient or physician plans or expects a reduction in services, or if the patient or physician electively cancels the procedure, modifier 52 (Reduced services) is appropriate.

Example: If a descriptor specifies a bilateral procedure but no code describes an equivalent unilateral procedure, and the physician provides the service on one side of the body 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. For instance, a child already has a hearing aid on the right side. Therefore, the ENT instructs the audiologist to test the left ear only. You would assign 92552-52 (Pure tone audiometry [threshold]; air only).

In contrast, if the physician reduces the service due to unexpected complications that place the patient at unacceptable risk, modifier 53 (Discontinued procedure) is appropriate. That is, the physician intends to provide the complete service but cannot do so due to unusual or extenuating circumstances.

Example: The ENT cuts short a surgical service due to extensive hemorrhaging or adverse reaction to anesthesia.

In your case, the ENT 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, and you should report 69210-52 (Removal impacted cerumen [separate procedure], one or both ears).

Reimbursement tip: When appending either modifier 52 or 53, provide documentation with the claim explaining the reason the service was reduced or terminated. Do not reduce your fee: Allow the payer to make a reimbursement decision based on documentation.

Clinical and coding expertise for You Be the Coder and Reader Questions provided by Barbara J. Cobuzzi, MBA, CPC, CPC-H, CHBME, president of CRN Healthcare Solutions, a coding and reimbursement consulting firm in Tinton Falls, N.J.; and Charles F. Koopmann Jr., MD, MHSA, professor and associate chair at the University of Michigan's department of otolaryngology in Ann Arbor.