Cardiology Coding Alert

Modifiers Critical When Coding for Terminated Procedures

When a procedure fails, do you have to lose money, too? What modifiers can you attach to recoup reimbursement? Several of our readers want to know.

How can I get reimbursed for my time and effort for failed procedures? asks W.R. Ross, MD, Interventional Cardiovascular Associates in Hackensack, NJ.

Similarly, Sabina Valentine, business office representative at the New Brunswick (N.J.) Cardiology Group, wants to know how to bill for a failed left heart catheterization. She explains that the cardiologist attempted a left heart catheterization via the right femoral artery, but he was unable to advance the wire through the abdominal aorta, so the cath was aborted.

Should we attach modifier -53 (discontinued procedure) or modifier -52 (reduced service)? Valentine asks.

What modifiers your cardiology practice uses, as well as the reimbursement it might receive, depends on why the physician did not complete the procedure in addition to how much of it he or she actually completed before stopping, explain coding experts.

Heres a rule of thumb you can depend on: If the physician stops the procedure because it is endangering the welfare of the patient, you would append modifier -53, (discontinued procedure). But if the physician is not able to complete the procedure for other reasons, such as the anatomy of the patient, you would append modifier -52 (reduced services).

In the case described above, the correct modifier is -52. The report says the cardiologist could not complete the procedure because of an anatomical problem, which prevented him from performing the catheterization as described in the CPT manual . This, he elected to stop.

This is the distinguishing difference between modifier -52 and -53, explains Sueanne Bicknell, RRA, CCS-P, reimbursement and compliance specialist at Cardiovascular Provider Resources-Heart Place in Dallas, Texas. Modifier -52 reflects that it was the doctor who could not complete the procedure [as outlined in CPTs description for that procedure code], while modifier -53 shows that the doctor decided to discontinue the procedure because something happened with the patient.

Tip: Unfortunately, you cant use modifier -53 if the patient cancels the procedure prior to anesthesia induction and/or surgical preparation. You dont get paid of the patient changes his or her mind, says Sheila Sylvan, principal, IMPACT Medical Management, a coding consulting firm in Atlanta, Ga.

Educate Staff

Bicknell, who performs operative report audits and charge reviews for her practice, found her staff had similar problems in determining which modifiers to use and when to use them. Using the following examples, Bicknell distributed a memo to all of her physicians, charge entry staff and practice managers clarifying the appropriate use of modifiers -52 and -53.

Example 1 (modifier -52): The cardiologist performs a left heart cath and a PTCA. But the documentation shows the attempted PTCA of the totally occluded left circumflex failed and the patient was then scheduled for bypass surgery. Because the PTCA procedure could not be performed as defined by CPT code guidelines, it would be coded as 92982-52, she says.

Example 2 (modifier -53): If the cardiologists aborts a diagnostic heart cath after initial catheterization of the femoral artery because the patients blood pressure could not be stabilized, then you would code as 93510-53. You would use this modifier because the procedure could not be continued due to contraindications, Bicknell explains.

Modifier -53, she says quoting the CPT manual, is specifically used when there are extenuating circumstances that threaten the well being of the patient.

It differs from -52, which describes a procedure that was terminated at the physicians discretion, in that a patients life-threatening condition precipitated the terminated procedure, she says.

Filing Incomplete or Canceled Procedures

You cant file an electronic claim for incomplete or canceled procedures, because the Health Care Finance
Administration guidelines require payers to manually review all claims with modifier -52 or -53, explains Bicknell.

Operative report documentation is extremely important when billing services with these modifiers as reimbursement is directly assigned based on the procedure documentation, she stresses. The reason is that the payer calculates the amount to pay based on how much of the procedure was completed.

There is no set percentage of the allowable fee; it
depends on what the operative report shows and how the payer calculates reimbursement for that portion of the procedure that was completed, explains Susan Stradley, CPC, CCS-P, senior consultant for Elliott Davis and Co., LLP, headquartered in Greenville, S.C.

It may be 50 percent [of the amount due], it may be less or it may be more, says Stradley. For example, the patient may have crashed in the last five minutes [of a lengthy procedure], so you would be entitled to more reimbursement than if it had happened immediately after the procedure began.

The crucial element, say Stradley and Bicknell, is to append the appropriate modifier. When you attach modifier -53, the payer reviews the claim and operative report, looking specifically for dictation that supports or identifies the extenuating circumstances that threaten the well being of the patient, which required the procedure to be discontinued, points out Bicknell.

But if the operative report supports only that the procedure could not be completed, based on the CPT code
description, then the payer will deny any payment for the claim as inappropriate use of modifier, Bicknell says.

In that case, you would have to resubmit an amended claim, showing modifier -52, along with the operative report.

Bicknell explains that payers determine the reimbursement allowed based on the documentation of the following:

reason for termination
extent of the CPT procedure actually performed

Thats why you have to submit an op report and let the carrier determine the amount of payment, reminds Stradley.

The insurance company will determine the reduction. Do not increase or reduce your own fees. Otherwise, you may receive more or less than the reimbursement to which you are entitled, Stradley says.

Don't Use Modifiers -73 and -74

Experts also tell us some cardiology practice coders are confusing modifiers -52 and -53, which were added to CPT 97, with modifiers -73 and -74, which were added to CPT 99. (Modifier -73 indicates a discontinued procedure prior to the administration of anesthesia, and modifier -74 indicates a discontinued after administration of anesthesia.)

While both sets of modifiers are used to indicate discontinued procedures, -73 and -74 are facility codes, and should only be used in ambulatory surgery centers (ASC), explains Sylvan.

Many physician practices do minor surgical procedures, but they are not ASCs and therefore should not use the new outpatient modifiers, she says. In order to be considered an ambulatory surgery center, you must have certificate of need and be licensed.