ED Coding and Reimbursement Alert

CompleteYour Claims for Incomplete Procedures

Your physician may have to stop treating a patient before she completes the procedure - but don't abort your codes before adding modifier -52 or -53.

Coders often misuse modifiers -52 (Reduced services) and -53 (Discontinued procedure), and with good reason. Technically, both modifiers can describe procedures that are cut short, and both can cite the patient's well-being or other extenuating circumstances as reasons for discontinuation. But here's the key: More often than not, modifier -53 indicates a procedure the physician aborted before completion because continuation posed a threat to the patient's health. Modifier -52, on the other hand, is more appropriate when the procedure simply requires less work, less intense work, or is atypical in some way.

According to Principles of CPT Coding, published by the American Medical Association, you should not append modifier -53 unless the physician decides to discontinue the procedure after she administers the anesthesia. Also, you shouldn't use this modifier when the surgeon's problem spurs the discontinuation - such as a scheduling conflict or equipment failure - rather than the patient's.

Modifier -53: The Cure Is Worse Than the Disease

You should use modifier -53 when urgent or critical situations arise that place the patient in immediate danger. "If the physician's intent is to carry out the procedure to completion - but the patient is unable to tolerate the procedure to the point that his health or well-being is at risk - and the physician ends the procedure prematurely, you should append modifier -53 to the procedure," say Carol Pohlig, BSN, RN, CPC, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia.

For example, if the ED physician is using conscious sedation or anesthesia and the patient has an adverse reaction to the sedative, such as internal bleeding or failure of vital signs, she won't complete the procedure, and you should append -53.

Or let's say the physician was performing a lumbar puncture (62270*, Spinal puncture, lumbar, diagnostic) and the patient suddenly had tingling and numbness in his left leg. Out of concern for the patient's safety, the doctor terminates the procedure without retrieving cerebrospinal fluid. You would report this procedure as 62270-53 to indicate that the physician began the procedure but couldn't finish it.

For public-relations reasons, some physician groups elect not to bill for incomplete procedures that were painful for the patient, but experts disagree about this practice. Some say it's a matter of courtesy, but others think you should bill regardless of the service's outcome.

"The physician should be paid for the service he or she performed, even if he was unable to complete the service," Pohlig says. "A physician must attempt to recover the cost of the equipment, supplies, staff and effort associated with the portion of the procedure that was carried out."

You should append modifier -52 when "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 elects not to do part of the procedure or if the case presented did not require a full procedure, modifier -52 is applicable."

For instance, an ED physician starts to place a femoral line in a patient. He establishes the line, places the wire and threads it into the vein, and threads the dilator over the wire. He successfully threads the triple-lumen catheter into the first few centimeters of the vein, when he meets an obstacle - the catheter kinks. He must discontinue the procedure.

Since the truncated procedure resulted from a complication rather than from a threat to the patient's health, you should report modifier -52. In this case, you would use 36489*-52 (Placement of central venous catheter [subclavian, jugular, or other vein]; percutaneous, over age 2). In this case, too, some physicians opt not to bill, depending on the public- relations policies of their practices.

Even when you know the right times to use -52 and -53, there are still unfinished procedures that can throw you for a loop - in some instances, a truncated procedure actually qualifies as an entirely different procedure.

Usually, a colonoscopy (45378, Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen(s) by brushing or washing, with or without colon decompression) includes an exam of the entire colon, from the rectum to the cecum, and may extend into the ileum. But if for some reason the ED physician can't advance the examination beyond the splenic flexure, he can't complete the colonoscopy. He has, however, performed another procedure in full: a flexible sigmoidoscopy (45330, Sigmoidoscopy, flexible; diagnostic, with or without collection of specimen[s] by brushing or washing). So instead of reporting the colonoscopy code with modifier -52, you should code the sigmoidoscopy.

You have three options when you charge for incomplete procedures:

1. Use modifier -53, which will reduce your charges.
2. Use modifier -52, which will reduce your charges.
3. Don't charge for the procedure at all.

While many ED physicians opt not to charge for unsuccessful or incomplete procedures - especially if the patient was in pain - that rule of thumb doesn't match facility guidelines, which require coding for the procedure regardless of its completion.

Mismatched facility and physician codes might not look good to a hospital auditor, but that doesn't necessarily mean you need to report the procedure simply because the hospital does. Just use common sense: If the physician performed the major steps of the procedure, append a modifier and reduce the charges. If she did very little of the procedure, don't charge.

Ultimately, your best bet is to check with your insurer about its policies, Pohlig says. "Claims that include these modifiers are never paid electronically, because the carrier wants to review the documentation and make its own determination of how much of the procedure was completed - and how much it will pay," she says. While Medicare accepts these modifiers,  non-Medicare insurers do not necessarily recognize the modifiers on their systems. "So depending on the payer, the claim may go in and get paid, get denied, or the documentation may be requested."