Neurology & Pain Management Coding Alert

In certain circumstances, neurologists may find it necessary to alter or discontinue a procedure at the physician's discretion or because of unanticipated risk to the patient. When this occurs, modifiers can be used to inform the payer that a defined service was attempted, but altered by specific circumstances.
Two modifiers are commonly used in these situations. Modifier -52 indicates that a service was reduced or eliminated at the neurologist's discretion. Modifier -53 identifies a procedure as having been terminated due to circumstances that create risk for the patient.
These two modifiers are often confused, as they both define a service as having been altered in some way. They provide a means to report the alteration without disturbing the identification of the basic service described by the code. Both modifiers typically lower the level of reimbursement. But they are not interchangeable, and a closer look at how they are properly used can help coders and neurologists differentiate between them.         Use -52 to Show a Change in the Service   CPT defines modifier -52 as follows: 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.  
The key to this description is the phrase "at the physician's discretion," notes Laureen Jandroep, OTR, CPC, CCS-P, owner of A+ Medical Management & Education in Egg Harbor City, N.J. Jandroep provides coding and reimbursement training and research, as well as chart auditing and consulting. This phrase tells the payer that medical decision-making was involved in altering the service.
"The neurologist may determine that it is appropriate to provide the service at a lesser level than the complete description indicates," Jandroep says. "For example, modifier -52 can be used if a procedure is bilateral in nature, but only one side is done."
Codes 95925-95927 can illustrate this usage. Code 95925 is used for short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in upper limbs. Code 95926 describes the same service in the lower limbs. Code 95927 references the trunk or head. With any of these codes, modifier -52 can be used to report a unilateral study.   Jandroep explains that modifier -52 can also be used when there is no code that is an exact description of the service provided.
"The neurologist may determine that it is appropriate to provide the service, but minus a small portion of it," Jandroep says. "The description of the procedure may include four components, but the neurologist makes the decision to do only three of [...]