General Surgery Coding Alert

If you're appending modifier -52 or -53 to a claim, you want to tell the payer why. Include a cover letter -- as well as the operative report -- with your claim to explain the extenuating circumstances that caused the physician to reduce or discontinue 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.

For instance, if the patient becomes uncooperative, you should note this as the reason for terminating the service (for instance, "During colonoscopy, the patient wished to discontinue the procedure due to discomfort"). Or, if the patient becomes dangerously unstable during a procedure, you should explain these conditions as well (for example, did the patient's blood pressure rise suddenly? Did he begin to convulse? What exact symptoms led to the discontinuation of the service?).

"The rules of medical necessity don't go out the window just because you append -52 or -53," Jandroep warns.

You should never lower you fees when submitting a claim with modifier -52 or -53. Rather, you should provide as much documentation and explanation as possible and allow the payer to make a determination based on the information you submit, Jandroep says.

"If you reduce your fee up front, the payer may take an additional reduction on top of that. Additionally, remember that the fees you charge become part of a database of reasonable and customary fees. If you submit a reduced fee, that can distort the collected data," Jandroep says.

You should also consider that a terminated procedure might not necessarily mean less effort than a completed procedure. If the physician makes several unsuccessful attempts to perform colonoscopy, for instance, he may actually work harder than if the procedure had gone as planned. This is also true if you are dealing with a difficult or younger patient who refuses to complete a procedure.