Wiki Pessary Fitting Unsuccessful

[MollyS]

We're having a discussion in my office about billing for unsuccessful pessary fittings, and opinions differ.
If the fitting is performed, trialing one or more pessary sizes/types, but the final insertion is not done should a modifier be appended to CPT 57160?

• modifier-53 discontinued - because patient decided to stop trial and/or procedure wasn’t completed - no insertion.
• modifier-52 reduced service - because final pessary insertion was not done.
• 57160 without a modifier because the fitting was performed. Procedure considered unsuccessful, not reduced or discontinued.

Sample note:

I explained the process of the pessary fitting. Discussed that we could stop if she was uncomfortable.​

Tried the following pessaries:​

#3 ring w/ support was too small and slipped down when standing​

#4 ring w/ support w/ knob - felt ongoing bulge​

#3 & #4 gearing w/ knob - too large to fit​

At this point patient decided to stop further trials for today.​

 

[nielynco]

We're having a discussion in my office about billing for unsuccessful pessary fittings, and opinions differ.
If the fitting is performed, trialing one or more pessary sizes/types, but the final insertion is not done should a modifier be appended to CPT 57160?

• modifier-53 discontinued - because patient decided to stop trial and/or procedure wasn’t completed - no insertion.
• modifier-52 reduced service - because final pessary insertion was not done.
• 57160 without a modifier because the fitting was performed. Procedure considered unsuccessful, not reduced or discontinued.

Sample note:

I explained the process of the pessary fitting. Discussed that we could stop if she was uncomfortable.​

Tried the following pessaries:​

#3 ring w/ support was too small and slipped down when standing​

#4 ring w/ support w/ knob - felt ongoing bulge​

#3 & #4 gearing w/ knob - too large to fit​

At this point patient decided to stop further trials for today.​

Per the vignette submitted with this code to CPT the work would be as follows: Insert the fitting pessary into the vagina. Assess the prolapse reduction. If inadequate reduction is achieved or the device is immediately painful, remove the device and select and place an alternative pessary model. Provocative maneuvers are performed while in the dorsal lithotomy position with direct physician observation after the initial evaluation for reduction and pain. Again, assessment is made of prolapse reduction. When complete reduction has been achieved, query patient regarding device comfort. If not uncomfortable, instruct the patient to sit, stand, walk, and perform provocative maneuvers in a standing position to assess device comfort and efficacy. Then re-examine the patient in the dorsal lithotomy position. If the patient experiences extrusion of the device, significant movement of the device, or pain, restart the fitting trial with a new fitting pessary style or size. Continue this process until an appropriate pessary is identified that effectively supports the prolapse and is not uncomfortable. Instruct the patient in the insertion and care of the pessary. If she has no physical limitations that prevent self-care, ask her to demonstrate removal and insertion of the pessary. Vaginal examination is repeated at that time to confirm patient has achieved proper placement without vaginal trauma.

If less than this was done, and it appears it was, a modifier -52 would be appropriate to add a modifier -52 to the code.

 

[MollyS]

Thank you for your help!!
Using the vignette you provided - if our providers are performing all of the work involved in the fitting process (portion in red below) but unable to achieve a comfortable, appropriate fit then we should report modifier -52?

Insert the fitting pessary into the vagina. Assess the prolapse reduction. If inadequate reduction is achieved or the device is immediately painful, remove the device and select and place an alternative pessary model. Provocative maneuvers are performed while in the dorsal lithotomy position with direct physician observation after the initial evaluation for reduction and pain. Again, assessment is made of prolapse reduction. When complete reduction has been achieved, query patient regarding device comfort. If not uncomfortable, instruct the patient to sit, stand, walk, and perform provocative maneuvers in a standing position to assess device comfort and efficacy. Then re-examine the patient in the dorsal lithotomy position. If the patient experiences extrusion of the device, significant movement of the device, or pain, restart the fitting trial with a new fitting pessary style or size. ​

Continue this process until an appropriate pessary is identified that effectively supports the prolapse and is not uncomfortable. Instruct the patient in the insertion and care of the pessary.​

 

[nielynco]

Thank you for your help!!
Using the vignette you provided - if our providers are performing all of the work involved in the fitting process (portion in red below) but unable to achieve a comfortable, appropriate fit then we should report modifier -52?

Insert the fitting pessary into the vagina. Assess the prolapse reduction. If inadequate reduction is achieved or the device is immediately painful, remove the device and select and place an alternative pessary model. Provocative maneuvers are performed while in the dorsal lithotomy position with direct physician observation after the initial evaluation for reduction and pain. Again, assessment is made of prolapse reduction. When complete reduction has been achieved, query patient regarding device comfort. If not uncomfortable, instruct the patient to sit, stand, walk, and perform provocative maneuvers in a standing position to assess device comfort and efficacy. Then re-examine the patient in the dorsal lithotomy position. If the patient experiences extrusion of the device, significant movement of the device, or pain, restart the fitting trial with a new fitting pessary style or size. ​

Continue this process until an appropriate pessary is identified that effectively supports the prolapse and is not uncomfortable. Instruct the patient in the insertion and care of the pessary.​

So if they did not instruct the patient on how to insert it and how to care for it, part of the work was not done. Modifier -52 does not stipulate what portion was not done, just that the expected work was not completed. You should submit this information to the payer.