General Surgery Coding Alert

Unscramble ‘reduced’ and ‘discontinued’ procedures.

When your surgeon stops a procedure before completing it to the fullness of the CPT® code description, what should you do?

Know your choices: You might use modifier 52 (Reduced services), or modifier 53 (Discontinued procedure), or you might use a different code that accurately describes the work completed.

Let our experts help you unravel the choices so that you can increase your coding accuracy and ethically maximize the pay your surgeon deserves when these limiting circumstances occur.

Use 52 for ‘Lessened’ Procedures

Sometimes a specific CPT® code is the best option available to describe a procedure, even if it describes a little more work than the surgeon actually performs.

Generally, you should use modifier 52 “to indicate that the service was provided as described by the CPT® code description — but not fully,” says Laureen Jandroep, CPC, CPC-H, CPC-I, CPPM, CMSCS, CHCI, founder and CEO at CodingCertification.org in Oceanville, N.J. “It usually indicates the fee should be reduced.”

In other words, modifier 52 typically indicate that the service is most like the procedure that fits the code descriptor, but significantly less than the typical procedure entails.

For instance: Based on pathology findings, a surgeon performs a colonoscopy to biopsy tissue in the transverse colon from a site where she had previously removed a polyp. Because the surgeon advances the scope only to the prior polypectomy site, which is beyond the splenic flexure but not all the way to the cecum, you should report the service with an appropriate code such as 45380 (Colonoscopy, flexible; with biopsy, single or multiple) with modifier 52.

Caution: If the procedure is so truncated that another code better describes the service, make sure to use the more-specific code rather than applying a modifier to an intended procedure.

For instance: If the surgeon sets out to complete a diagnostic colonoscopy (45378, Colonoscopy, flexible; diagnostic, including collection of specimen[s] by brushing or washing, when performed [separate procedure]), but does not reach the splenic flexure due to blockage, you should not report 45378, even with modifier 52. Instead, you should select a code that more accurately describes the performed procedure, such as 45330 (Sigmoidoscopy, flexible; diagnostic, including collection of specimen[s] by brushing or washing, when performed [separate procedure]).

Tackle Terminated Procedures with 53

When you append modifier 53 to a procedure code, you’re telling the payer that the surgeon stopped the procedure before completing it. Typically, modifier 53 involves cases when the surgeon halts a procedure because the patient’s health and well-being are at risk.

Example: Your surgeon decides to discontinue a hernia repair (such as 49525, Repair inguinal hernia, sliding, any age) because the patient develops respiratory distress, and continuing the procedure could be risky and might endanger the patient’s well-being. In this case, report 49525 with modifier 53.

Watch out: You can’t use this modifier when the patient elects to cancel the procedure or service. In fact, CMS states that modifier 53 “is not used to report the elective cancellation of a procedure prior to the patient’s anesthesia induction and/or surgical preparation in the operating suite.”

Check Note for Complete Details

No matter what modifier you use for which situation, payers will need to see thorough notes explaining why the service ended.

“In the case of either modifier 52 or 53, the documentation needs to reflect the circumstances that necessitated reducing or discontinuing the procedure,” says Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians in Leawood, Kan.

“Additionally, in the case of modifier 52, I believe the documentation should reflect the extent to which the service was reduced (how much of the procedure was done and what was left undone),” he says.