General Surgery Coding Alert

Knowing why the physician halted the procedure matters for modifiers -52/-53

When a surgeon provides a less-than-total service, either by choice or necessity, you can quickly decide between modifiers -52 and -53 to describe the situation by asking yourself, "Why did the physician stop the procedure?"

When 1) the surgeon plans or expects a reduction in the service, or 2) the surgeon electively cancels the procedure prior to completion, you should append modifier -52 to the appropriate CPT code.

Modifier -52 (Reduced services) -- Under certain circumstances a service or procedure is partially reduced or eliminated at the physician's discretion. Under these circumstances the service provided can be identified by its usual procedure number and the addition of the modifier '-52,'signifying that the service is reduced (CPT 2004, Appendix A).

To apply modifier -52, the reduction of services must have occurred by choice (either the surgeon's or the patient's) rather than necessity.

"For example, the surgeon may determine that it is appropriate to provide the service at a lesser level than the complete description indicates, or the patient may elect to cancel the procedure," says Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, director and senior instructor for CRN Institute, an online coding certification training center based in Absecon, N.J.

Example A: The surgeon performs a pelvic lymphadenectomy on the right side. In this case, because CPTdoes not contain a code describing unilateral lymphadenectomy, you should report 38571 (Laparoscopy, surgical; with bilateral total pelvic lymphadenectomy) and append modifier -52 to describe a reduced service.

Example B: The surgeon begins 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 [separate procedure]), which includes an exam of the entire colon, from the rectum to the cecum (and possibly into the ileum). During the exam, however, the surgeon finds he cannot advance the examination beyond the splenic flexure. In this case, you should report 45378-52 to denote the "reduced" service, according to CPTguidelines.

When the physician terminates a procedure because continuation of that procedure puts the patient's health at risk, you should append modifier -53 to the appropriate CPT code. You should not append modifier -53 if the surgeon electively cancels a procedure prior to the administration of anesthesia or surgical preparation in the operating room, according to CPT guidelines.

Modifier -53 (Discontinued procedure) -- Under certain circumstances, the physician may elect to terminate a surgical or diagnostic procedure. 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. This circumstance may be reported by adding the modifier '53'to the code reported by the physician for the discontinued procedure (CPT 2004, Appendix A).

"Modifier -53 describes an 'unexpected problem,' beyond the physician's or patient's control, that necessitates the termination of the procedure," says Carol Pohlig, BSN, RN, CPC, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia. "The physician doesn't so much elect to discontinue the procedure as he or she is forced to do so."

In addition to circumstances that put the patient's health at risk, you might also choose modifier -53 if the surgeon must halt the procedure due to equipment failure or because he cannot go on (for example, the surgeon cuts himself and cannot continue).

Example C: The patient arrives in the operating suite for repair of an abdominal aneurysm (35081, Direct repair of aneurysm, pseudoaneurysm, or excision [partial or total] and graft insertion, with or without patch graft; for aneurysm, pseudoaneurysm, and associated occlusive disease, abdominal aorta). While the surgeon attempts to access the aneurysm, the patient develops significant cardiac arrhythmia.

Although the anesthesiologist works to control the premature ventricular contractions, the surgical team decides to discontinue the procedure because of the potential risks to the patient. In this case, you should report 35081-53. You should include an operative note explaining why the surgeon discontinued the procedure and what percentage of the surgery he completed.

Example D: The surgeon begins a laparoscopic colectomy (44210, Laparoscopy, surgical; colectomy, total, abdominal, without proctectomy, with ileostomy or ileoproctostomy). The patient has received anesthesia, but prior to creating the incision, the surgeon has problems with the camera. Because of mitigating factors, the surgeon cannot convert to an open procedure. The surgeon abandons the procedure and reschedules for a later date. You should report 44210-53 and include documentation with the claim.