When Not to Use Modifiers 52, 53

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  • In Coding
  • August 16, 2010
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Recent guidance from Palmetto GBA Medicare sets a good example of why it is so important for coders to pay careful attention to code descriptions and documentation.
The Part B Medicare administrative contractor (MAC) for jurisdiction 1 sites a coder’s question:
“Due to an adverse reaction to Rituximab, an infusion scheduled for over one hour was discontinued after 10 minutes. The physician conducted an examination and returned the patient to the care of the nurse for an additional hour of monitoring. Can we be reimbursed for the entire hour?”
“If we bill the administration as a push, or add CPT modifier 52 (reduced service) or 53 (discontinued service) to the infusion code, we will receive lower reimbursement.”
Palmetto advises the coder as follows:
“Since the intent was for an infusion, CPT code 96413 (chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug) would be more appropriate than billing as a push. The definition of CPT code 96413 states ‘up to one hour;’ therefore, the use of CPT modifier 52 or 53 would not be mandatory, especially with the additional time spent monitoring the patient after the infusion was stopped. Please note that documentation in the medical record of all time spent with the patient is critical. Use of CPT modifier 52 or 53 may result in reduced reimbursement, depending on the documentation submitted with the claim.”

No Responses to “When Not to Use Modifiers 52, 53”

  1. Brenda Hughes says:

    If a patient is scheduled for a screening colonoscopy and the physician states he found insignificant hemorrhoids & diverticulosis, should 455.0 and 562.10 be coded as secondary diagnoses along with V76.51?

  2. Imy Tabaquin-Fruto, CCS, CPC, CPC-H says:

    If the patient was scheduled for screening then V76.51 would be your primary dx followed by the findings. ‘hope this helps.

  3. Bonnie P says:

    Regarding using the V76.51 as primary when a patients colonoscopy resulted in abnormal findings: I was taught that once you had a definitive diagnosis you were to use this as primary. Since the screening resulted with abnormalities they were the only diagnosis that need to be used. If everything was normal then the screening code would be used. Was I taught wrong?

  4. Anna Barnes, CPC, CEMC, CGSCS says:

    Screening colonoscopies are one of those exceptions to the rule. Medicare has actually adderssed this by stating that if the intention is to perfrom a screening colonoscopy and a diagnosis is found (polyps, hemorrhoids, diverticulosis, etc). Code the screening code ( V76.51) primary and the diagnosis 2nd: reference the definitive diagnosis. For example, Md performed a 45385 and 1.) V76.51, 2.) 211.3, 3.) 562.10. Reference diagnosis would be 2. (211.3). Your PM system has to be able to do this. Most carriers follow this guideline. You can research with your major carriers.

  5. Deana Tuley says:

    Can you provide the Medicare resource (transmittal) for this exception?

  6. harish says:

    According to the ICD-9 CM guidelines 18.d.5, “A screening code maybe a first listed code if the reason for the visit is specifically the screening exam. Should a condition be discovered during the screening then the code for the condition maybe assigned as an additional diagnosis”.