Pediatric Coding Alert

Also: know which one could even apply to a wastage situation.

As you know, modifiers are useful because they provide the payer additional information for processing a claim. However, when you’re dealing with different services, procedures, and payers, appending the incorrect modifier can sometimes be the reason a claim is denied.

Denials are particularly common when coders start appending modifiers 52 (Reduced services) and 53 (Discontinued procedure). If you could use a crash course in when and how to properly use these modifiers, we’ve got you covered.

Meet the 52 and 53 Modifiers

Generally, the confusion with modifiers 52 and 53 lies in the terms “reduced” and “discontinued.” What’s the clinical difference between the two? Consider the following:

Modifier 52: Use this modifier when a physician completes the procedure but elects to reduce a portion of the service or procedure for reasons other than the patient’s well-being.

Example: A 7-year-old presents to the clinic with a splinter in their finger. The physician attempts to remove the splinter, but due to its depth and the child’s discomfort, only a portion of it could be removed. The remaining part of the splinter is not causing any harm or severe discomfort to the child, so the physician decides to leave it in place and allows it to naturally come out with time. In this case, the procedure was partially successful, but not completed as typically described, so modifier 52 would be appropriate to append to the procedure.

Modifier 53: Use this modifier when the physician terminates the procedure due to extenuating circumstances or patient safety.

Example: A 5-year-old presents with a foreign body lodged in one eye. The physician begins the procedure to remove the foreign body. However, the child becomes extremely distressed and uncooperative, making it unsafe to continue the procedure. In this case, the pediatrician started the procedure but could not complete it due to extenuating circumstances. “Modifier 53 would need to be added to the procedure that was discontinued to identify that the procedure was discontinued,” says Julie Davis, CPC, CRC, COC, CPMA, CPCO, CDEO, CEMC, AAPC Approved Instructor, senior manager of compliance, Honest Medical Group in Parker, Colorado.

Documentation alert: When coding with modifier 52 or 53, you should provide easy-to-read, clear, concise documentation explaining in specific detail what the procedure accomplished, what did and didn’t occur and why, the patient’s condition, the circumstances that caused the discontinuation or reduction, and the detailed operative report. Be sure to check with your payers because some may refuse to pay for this modifier or have particular requirements for its use.

Know When to Look out For Laterality

Sometimes, procedures are generally performed bilaterally, or on both sides of the body. In pediatrics, the two procedures this mostly applies to are tonsillectomies and adenoidectomies. These procedure codes assume bilateral surgery, so if the patient requires a unilateral tonsillectomy and/or adenoidectomy, you’ll need to report the appropriate procedure code with modifier 52, per CPT^® Assistant (February 1998).

Notice Additional Nuances That Call for 52

The 52 modifier can prove useful in other kinds of situations. For example, let’s say the provider administered a flu vaccine to a young patient but due to the patient moving around, the provider was only able to get a portion of the vaccine into the child.

This is a situation that likely requires you append modifier 52 to the administration CPT^® code to indicate to the payer that the provider administered less than the amount planned. Note: you’ll need to still account for that wastage. For detailed information about that, check out the article titled, “Modify Your Understanding of Reporting Wastage with JZ and JW” from Pediatric Coding Alert volume 27, number 2.

Documentation alert: Chart documentation is going to be important with a claim like this one, as the payer is going to want to see a detailed account of what happened during the encounter. Make sure the documentation supports that the patient was moving around too much to receive the recommended amount of product.

However, you may be wondering why modifier 53 isn’t the more appropriate choice. Modifier 53, after all, refers to determination based on patient safety. A case could certainly be made for the patient’s movement during injection being a safety hazard.

However, most payers consider modifier 53 specific to surgical and diagnostic procedures only, which does not include routine vaccinations. “I might recommend that the patient’s safety be emphasized in addition to the difficulty of the procedure under the circumstances so as to underscore the unavoidable nature of this unusual outcome,” advises Jan Blanchard, CPC, CPEDC, CPMA, pediatric solutions consultant at Vermont-based PCC.

Tip: Though Modifier 52 is likely the most appropriate modifier to report this scenario, be sure to still check the payer policy. When it comes to pairing modifiers with procedures, some payers define “procedure” narrowly to mean invasive therapies only.