Urology Coding Alert

Question: A patient opted against moderate sedation during a vasectomy, and the urologist had to terminate the procedure midway through due to the patient experiencing a syncopal episode. Are there any guidelines for whether I should use modifier 52 or 53 in this case?

Mississippi Subscriber

Answer: Appending modifier 53 (Discontinued procedure) to 55250 (Vasectomy, unilateral or bilateral (separate procedure), including postoperative semen examination(s)) is appropriate for terminated surgeries “due to extenuating circumstances or those that threaten the wellbeing of the patient,” according to the CPT^® code book. Your example warrants the use of modifier 53.

While not applicable in this instance, you should also keep in mind that, according to Appendix A in the CPT^® code book, modifier 53 “is not used to report the elective cancellation of a procedure prior to the patient’s anesthesia 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.

You may use modifier 52 (Reduced services) in a variety of contexts, but not this example. For instance, you can append it to surgical codes that are inherently bilateral but that your surgeon performs unilaterally. However, keep in mind that for unilateral vasectomies, you should not append modifier 52 since the procedure includes both unilateral and bilateral services.