Primary Care Coding Alert

Answer: In certain circumstances, family practitioners (FPs) may find it necessary to alter or discontinue a procedure at the physician's discretion or because of unanticipated risk to the patient. When this occurs, you should use a modifier to inform the payer that the doctor attempted a defined service but had to alter it because of specific circumstances.

You will commonly use one of two modifiers in these situations. Modifier -52 (Reduced services) indicates that a physician partially reduced or eliminated part of a procedure at his or her discretion, according to CPT 2003, Appendix A. Modifier -53 (Discontinued procedure) identifies a procedure that the doctor terminates due to extenuating circumstances or circumstances that create risk for the patient.

In your scenario, the FP completed the procedure unsuccessfully he didn't obtain a sample. Consequently, you should report 36410* (Venipuncture, child over age 3 years or adult, necessitating physician's skill [separate procedure], for diagnostic or therapeutic purposes. Not to be used for routine venipuncture). The physician completed the procedure, but without success. Therefore, no modifier is necessary.

In contrast, if the FP chose to perform only part of a procedure and the CPT code describes a larger service, you would append modifier -52 to the procedure code. For instance, a patient complains of hearing loss in the right ear only, so the FP tests that ear only. Assign 92552-52 (Pure tone audiometry [threshold]; air only).