Podiatry Coding & Billing Alert

Question: My podiatrist performed a screw removal (20680), but he was unable to complete the procedure because the patient’s wellbeing was threatened. Can we bill for the procedure with a 52 modifier for reduced services or is there another modifier we can use?

Colorado Subscriber

Answer: You should use modifier 53 in this case. Modifier 53 (Discontinued procedure) is the correct modifier to report for terminated surgeries “due to extenuating circumstances or those that threaten the wellbeing of the patient,” according to CPT^®.

Modifier 53 “is not used to report the elective cancellation of a procedure prior to the patient’s aesthesia induction and/or surgical preparation in the operating suite.” This means when reporting physician services, you may not bill for the surgical service in any capacity if the procedure is terminated prior to anesthesia.

Modifier 52: On the other hand, you could append modifier 52 (Reduced services) to surgical codes that are inherently bilateral but that your surgeon performs unilaterally.