Wiki Modifier 52 OR 53 for Failed IUD Removal

[veloso]

Hi All,
Which modifier is correct 52? OR 53? because some have different views. Here is a very short Operative Report:

27 yo P0010 is here for IUD removal

BP 110/82 Pulse 91 Temp 97.7 Ht 5'3

PMH - None
PSH - appendectomy
Allergies - none

Abdomen soft
Speculum exam no strings seen
Bed side sono done- IUD seen intrauterine
Trans abdomen guided IUD removal tried but failed

A/ P
For IUD removal under hysteroscopic guidance
To be booked for Thursday.
Seen with Dr. XXX

Please help.

Thank you,
IVM

 

[CodingKing]

Id say 52 since they tried to completed it but became too complicated with the time and equipment. 53 is usually used when discontinuing due to patient welfare in danger for instance drop in BP, patient in pain etc.

 

[jvilla]

Per Noridian

52 is for services planned without anesthesia.
"This modifier is used to indicate partial reduction, cancellation or discontinuation of services for which anesthesia is not planned. The modifier provides a means for reporting reduced services without disturbing the identification of the basic service. It also identifies a situation where a physician reduces or eliminates a portion of a service or procedure." https://med.noridianmedicare.com/web/jeb/topics/modifiers/52

53 is for anesthetic-planned services, and may be reported to Prior or after the administration of anesthesia.
"This 53 modifier allows the physician community to state the surgical procedure was discontinued due to extenuating circumstances or a threat to patient well-being."
https://med.noridianmedicare.com/web/jeb/topics/modifiers/53

So if anesthesia wasn't planned for your IUD (most aren't, and local anesthetics do not count for general/MAC sedation), I would report modifier 52.

Though, by the looks of your note, I'm not sure that it is detailed enough to report a 58301-52. Then again, I code cardiology and not OB/GYN.

Hope this helps.

J.Villa CPC, CCS Kaiser Perm.

 

[veloso]

Your explanation helps a lot, thanks Jacob.