Radiology Coding Alert

The next time your physician's documentation reveals an imaging or interventional procedure halted before it meets full code descriptor requirements, don't fret. Follow these expert tips, and you'll be on your way to flawless claims in no time.

Modifier 52 (Reduced services) applies when "a service or procedure is partially reduced or eliminated at the physician's discretion," according to CPT's Appendix A, "Modifiers." You should use modifier 52 when "services are less than described by the code," says Pamela J. Biffle, CPC, CCS-P, ACS-DE, operations director for AAPC e-Learning, headquartered in Salt Lake City. "You don't have to plan on services being reduced to use modifier 52. Often the provider may not know until the service has started."

Alternatively: You should append modifier 53 (Discontinued procedure) when 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.

Generally, however, if the physician plans or expects a reduction in services, or if the physician electively cancels the procedure before it's complete, you should use modifier 52.

Example: Your radiologist isn't present for a percutaneous gastrostomy tube placement, but he reads and interprets the films. You should report 74350 (Percutaneous placement of gastrostomy tube, radiological supervision and interpretation) and append modifiers 52 and 26 (Professional component).

Facility tip: In an ambulatory surgery center or other facility setting, the facility reports the appropriate surgical procedure code for the case and appends modifier 73 (Discontinued outpatient procedure prior to anesthesia administration) or modifier 74 (Discontinued outpatient procedure after anesthesia administration), depending on when the physician canceled the case, says Suzan Hvizdash, CPC, physician educator for the University of Pittsburgh and past member of the American Academy of Professional Coders National Advisory Board.

But this applies only to the facility billing, not to the physician.

If a descriptor specifies a bilateral procedure, but no code describes an equivalent unilateral procedure and the physician provides the service on one side only, append modifier 52. In such a case, you must be certain that there is no designated CPT code to describe the lesser procedure.

Example: For a unilateral extremity angiography, you should report 75710 (Angiography, extremity, unilateral, radiological supervision and interpretation) rather than 75716-52 (Angiography, extremity, bilateral, radiological supervision and interpretation; reduced services).

Similarly, you should not apply modifier 52 to a "complete" exam code when you have a "limited" code available.

Example: If the patient has a left upper quadrant ultrasound, you should report 76705 (Ultrasound, abdominal, real time with image documentation; limited [e.g., single organ, quadrant, follow-up]), not 76700-52 (... complete; reduced services).

Use modifier 53 when the provider starts the procedure and then discontinues it because of extenuating circumstances, Hvizdash says. That is, the physician intended to provide the complete service but -- because of unusual or complicating circumstances threatening the patient's well-being -- he was unable to do so.

Example: A radiologist providing a catheter service may abandon the procedure due to an adverse anesthesia reaction. In this case, you should append modifier 53 to the procedure code.

Bonus: When you have billed a discontinued procedure using modifier 53, you can then bill that same code again without adding a modifier when the physician accomplishes the procedure even within the global of the first incomplete procedure. You cannot do that with modifier 52 claims.

Caution: You cannot use modifier 53 unless the physician has already initiated anesthesia, Biffle says. If the physician cancels a procedure prior to anesthesia, you cannot bill the surgical procedure code even with modifier 53 appended. Instead, if the physician performs and documents a history, exam and/or some level of medical decision-making (two of the three), you should bill the appropriate inpatient or outpatient E/M service code.

Pointer: Another way to tell whether a service needs 52 or 53 would be to consider whether the patient had the entire service the physician intended to provide.

Use modifier 53 when the radiologist discontinued the procedure without completing it as planned. Use modifier 52 when the radiologist performs a planned but reduced service. Although not foolproof, this method is very consistent when identifying which modifier to use.

When appending either modifier, provide documentation with the claim explaining the reason your physician reduced or terminated the service. Do not reduce your fee. Instead, allow the payer to make a reimbursement decision based on documentation.

Documentation should also contain an estimation of the total percent of the procedure that the radiologist performed and completed.