ED Coding and Reimbursement Alert

When a procedure is terminated due to patient intolerance or anatomical variance, the CPT Codes that normally would be reported seems inaccurate because it reflects completing the entire procedure. Instead, ED coders should append the procedure codes with either modifier -52 (Reduced services) or -53 (Discontinued procedure) to indicate that only a portion of the procedure was performed. Modifier -53:Well-Being of Patient Threatened According to the AMA, when an ED physician stops a procedure because the patient is not tolerating it, coders should use modifier -53. CPT 2002 states physicians may terminate surgical or diagnostic procedures: "Due to extenuating circumstances or those that threaten the well-being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued." Because the modifier's definition later refers to an "operating suite," some coders are concerned that modifier -53 does not apply to ED services. That is not the case. When a procedure is discontinued because it threatens the patient's welfare, you should use modifier -53 regardless of location. According to Carol Sissom, BS, CPC, senior consultant with Health Care Economics Inc. in Indianapolis, modifier -53 is typically assigned when an urgent or critical situation arises. "Perhaps the ED physician is using conscious sedation and the patient has a reaction to the anesthesia," she says. "In other instances, the patient might suffer from internal bleeding or his vital signs may begin to fail. All of these might be indications that the procedure should be halted. Modifier -53 could then be used."

For example, an emergency physician is performing a lumbar puncture (62270*, Spinal puncture, lumbar, diagnostic) when the patient develops tingling and numbness in her right leg. The doctor aborts the service before cerebrospinal fluid is retrieved. You should report 62270*-53. Modifier -52:Unable to Complete Full Procedure At other times, a procedure can't be completed because of anatomical variances or other circumstances that interfere with progress. "The physician begins a procedure but for some reason can't complete it," says Tammy Akason, MA, CPC, manager of reimbursement and pricing for MeritCare Health System in Fargo, N.D. "If the provider elected not to do part of the procedure or if the case presented did not require a full procedure, modifier -52 is applicable." Two examples illustrate when to use modifier -52: An ED physician attempts to place a femoral line in a young patient. The line is established, and the wire is placed and threaded into the vein. The dilator is then threaded over the wire into the vein. The triple-lumen catheter is successfully threaded into the first several centimeters of the vein. However, the physician meets resistance, the catheter kinks, and the procedure is [...]