General Surgery Coding Alert

Automatically appending modifier 52 could be costing you hundreds.

When your surgeon works with another physician during a procedure, you can face major coding challenges. If you don't coordinate your coding with the other physician's coder, both doctors could lose money and face audits.

Learn how to correctly code for these shared procedures with this real-world case study.

Scenario: A urologist and a general surgeon performed surgery on a patient. The urologist did the orchiopexy and performed the opening and closing. The general surgeon performed an inguinal hernia repair.

Coding dilemma: Which codes should each physician report, and what modifiers should the coders use, asks Betsie Wilson, CPC, professional fee coordinator and charge capture surgery team lead at University of Washington Physicians in Seattle, who presented this case study.

CPT and the Correct Coding Initiative (CCI) do not bundle the two procedures together. In fact, if your general surgeon performed both the hernia repair and the orchiopexy without another physician, you would report both procedure codes.

For this case study, each physician will report his portion of the procedure. You will report the appropriate inguinal hernia repair code -- such as 49500 (Repair initial inguinal hernia, age 6 months to younger than 5 years, with or without hydrocelectomy; reducible) or 49505 (Repair initial inguinal hernia, age 5 years or older; reducible). The urologist's coder will report the applicable orchiopexy code (54640, Orchiopexy, inguinal approach, with or without hernia repair).

As for deciding whether to attach modifier 52 (Reduced services) for your general surgeon in this case, you-ll need to talk with the physician and review his documentation.

Some experts say that opening and closing are such a small portion of a procedure that you should not append modifier 52 because the reduction in reimbursement would not be equal to the amount of time and effort-the open/closing normally takes. Some coders, however, feel that reporting the code without a modifier isn't correct coding either.

"I personally don't add the 52 because the opening and closing are such a minor portion of the procedure that I don't consider the procedure -reduced,-" says Michael A. Ferragamo, MD, FACS, clinical assistant professor at the State University of New York, Stony Brook.

"We have had several cases lately with other surgeons, and I have never thought to append modifier 52 because we didn't open and/or close," says Karla D. Garcia, CPC, coder for Dr. West and Dr. Mayo in Paducah, Ky.

Downside: If your payer reduces every case by a third of the regular fee because you append modifier 52 even when your surgeon completes the entire procedure but not the open/close tasks, your practice could be losing hundreds of dollars over the course of a year.

Alternative: Some coders disagree, and say that a surgeon would use modifier 52 in a co-surgery situation where another surgeon performing a separate procedure opened and closed the patient. The rationale is that the first surgeon bills for the procedure with modifier 52 attached, to indicate that the procedure was performed without opening and closing.

"If your surgeon did not open or close the patient, you would report your coding with a modifier 52," says Betsy Donnelly, CPC, PCS, multi-specialty coder at Martin Memorial Health Systems in Stuart, Fla. "For instance, while an ob-gyn is doing an open procedure, he notices a mass within the intestine and calls in a general surgeon. If the general surgeon does a colectomy, you would code the appropriate colectomy code with a mod 52."

Bottom line: You should use your best judgment based on the operative report and the rules your payer sets up for modifier 52.

Pitfall: Don't append modifier 53 (Discontinued procedure) because your surgeon didn't open or close. You look at modifier 52 when the physician completed what he or she set out to do but did so performing less than the complete procedure.

Use modifier 52, not 53, when the physician completed the surgery, but to a lesser extent than the code describes, Garcia says. "For me, the key phrase is -accomplished some result.-"

"An incomplete or cancelled procedure would use modifier 53, not modifier 52," agrees Laureen Jandroep, OTR, CPC, CPC-H, CPCEMS, coding analyst for CodeRyte, Inc. and senior instructor for codingcertification.org.

Prepare to submit documentation: When submitting claims with modifier 52 attached, that you bill the procedure out at the full fee and include a cover letter that explains what wasn't done and why.

"Don't reduce your fee or else the payer may reduce your reduction," Jandroep cautions. "Modifier 52 is one of those modifiers that will require documentation due to the varied circumstances. It is not a modifier that triggers a mathematical formula to be applied. Try to compare to a similar procedure represented by another CPT code that could help the payer price the reduced procedure accordingly," she suggests.

You should not use modifier 62 (Two surgeons) or modifier 80 (Assistant surgeon) in this case.

You would only report cosurgeons (using modifier 62) if the surgeons worked together on the same procedure and both are reporting the same CPT code, Ferragamo explains. In this case, each physician has his own procedure to report.

Example: Your general surgeon and another surgeon work together to perform a two-physician percutaneous gastrostomy (PEG) tube placement (43246, Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with directed placement of percutaneous gastrostomy tube). You and the other surgeon's coder would both report 43246-62.

Modifier 80 is not appropriate for this case study either, however. Technically, the surgeons are not assisting one another. Assisting is usually when they are both working together on a procedure (or procedures).

How it works: "If the surgeon is working on the hernia while the urologist is working on the orchiopexy, they are not assisting each other," Garcia explains. "They are not sharing equal work and responsibility for one procedure. Since they are both performing their own distinct procedure, you would bill your surgery alone, with no modifier."