Cardiology Coding Alert

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 [...]