Pediatric Coding Alert

Question: When our certified medical assistant (CMA) performs a hearing or vision screening and cannot get a result due to the child moving too much or not cooperating, should I still code the procedure? The CMA ends up spending more time on these cases than completed ones. Would this be regarded as a discontinued procedure or a reduced service?

Alabama Subscriber

Answer: You should report the screening codes, such as 92551 (Screening test, pure tone, air only) or 99173 (Screening test of visual acuity, quantitative, bilateral), provided the CMA fully documents the attempt and the reason she could not complete the tests, such as an uncooperative child. But you will need to choose the appropriate modifier carefully, as the difference between modifier 52 (Reduced services) and modifier 53 (Discontinued procedure) is often misunderstood.

According to Appendix A in the CPT^® manual, you should use modifier 52 when “a service or procedure is partially reduced or eliminated at the physician’s discretion.” On the other hand, you’ll use modifier 53 when, “under certain circumstances, the physician may elect to terminate a surgical or diagnostic procedure.” To further clarify, CPT^® adds the following:

“Due to extenuating circumstances, or those that threaten the well-being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued.”

So, the difference between the modifiers lies in whether the provider discontinued the procedure for the patient’s safety (modifier 53), or whether the service the provider performed is less than the service described by the CPT^® descriptor (modifier 52). Or, to put it another way, if the provider’s judgement is the sole reason to cancel or reduce the service, you would use modifier 52, but if the patient’s condition is the deciding factor for the provider ending the service, you would choose modifier 53. Most often, you would see modifier 53 decisions made in an emergency room or surgical setting rather than in pediatric or primary care.

In this situation, then, modifier 52 would be the correct one to use. Depending on payer guidelines, it should allow some payment for the amount of time trying to perform the service.