Cardiology Coding Alert

Do you know the CMS rule for partial S&I services?

If you automatically append modifier 52 every time your report suggests a service that doesn't quite meet a CPT code descriptor, you could be cutting your compensation unnecessarily. 

Here's the rundown on when you should -- and shouldn't -- append 52 (Reduced services).

Gather Up CPT and CMS Guidance

AMA CPT guidelines explain that you should use modifier 52 when the physician partially reduces or eliminates a service or procedure at his discretion, says Stacie L. Buck, RHIA, CCS-P, LHRM, vice president of Southeast Radiology Management in Stuart, Fla.

CMS guidelines say to use 52 "when a procedure/service performed is significantly less than usually required," Buck says.

What to do: Report the usual code for the procedure and append 52 to indicate reduced services, Buck says, citing CPT guidelines.

Example: The cardiologist attempts an angioplasty to the left anterior descending coronary artery. He is able to cross the lesion with the guide wire, but the balloon will not fully cross the lesion because of its small diameter.

The cardiologist dilates what he can, but the results are poor. He refers the patient for coronary artery bypass surgery. In this case, you should report the coronary angioplasty code 92982 (Percutaneous transluminal coronary balloon angioplasty; single vessel) with modifier 52 attached.

Caution: Different payers may have different coding guidelines for this service.

Avoid Modifier 52-53 Mistakes

Modifier 53 (Discontinued procedure) is not interchangeable with 52. You should append 53 to a procedure code when an unexpected patient response, such as arrhythmia, ends the procedure, according to CPT Assistant, December 1996, Buck says. Remember: You should use 52 when the physician reduces a procedure at his discretion, not because of a life-threatening situation.

Bottom line: Look for why the physician didn't carry out the full procedure to determine whether you should append 52 or 53, Buck says.

Radiologic supervision and interpretation (RS&I) codes require performance of the exact services they describe -- supervision and interpretation. For example, you'll see this descriptor in "G" codes specific to renal and iliac angiography performed at the time of a heart catheterization (G0275 and G0278).

"Supervision" means personal supervision, including presence, during the radiologic portion of a procedure, according to CMS, Buck says. Important: Personal supervision is a service to a beneficiary -- it is not the same as general supervision, which fiscal intermediaries  pay hospitals for as physician services, Buck adds, citing CMS.

A different physician may perform the interpretation. CMS says that when one physician, such as a cardiologist, reports the supervision portion of the S&I code, and a radiologist reports the interpretation, each physician should append 52 to reflect the reduced service, Buck says.

Watch for: These are CMS' rules. Other payers may not recognize 52, Buck says. Check each payer's guidelines to be sure.

Act Early to Prevent Payment Problems

Smart idea: Send in documentation with a cover letter that illustrates the reduced procedure to prevent payment delays, says Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, CPC-EMS, CodeRyte Inc. coding analyst and coding review teacher.

Your cover letter should include an approximation of how much of the procedure your physician performed (such as 80 percent) to help the claims reviewer determine the value of your cardiologist's services. Your claims reviewer may not be an expert in your specialty, so use plain language to clearly show the work that deserves payment.

Tip: With a modifier like 52, which reduces compensation, don't submit a lower-than-usual fee. Leave any fee reduction up to the carrier. Submitting a reduced fee could cause the payer to slash your already-diminished compensation, Jandroep says.