When Not to Use Modifiers 52, 53
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.”