Ob-Gyn Coding Alert

"Just because you cant complete a procedure, doesnt mean you cant get paid for it. Understanding the meaning of modifiers -52 (reduced services) and -53 (discontinued procedure) can help ob-gyn practices obtain reimbursement dollars rightfully owed to them when procedures are unsuccessful, abandoned, or just go wrong.

Confusion over modifiers -52 and -53 arises when coders, physicians, and even payers fail to carefully read and understand the CPT Appendix A in which the modifiers are described.

People are not reading what the book says, and then dont interpret it correctly, says Melanie Witt, RN, CPC, MA, program manager in the department of coding and nomenclature at the American College of Obstetricians and Gynecologists (ACOG) in Washington, DC. Further complicating modifier use, she adds, are insurance companies and other payers that dont keep track of changes in CPT, and fail to program their computerized claims systems to recognize some or all modifiers. Sometimes they just flatly refuse to accept them.

So, how can ob-gyns get paid when they perform a procedure that turns out to be incomplete? The answer, experts say, is to properly code what services were actually rendered, and be sure to document them well, because they may be reviewed manually. Exactly how much of a service has been reduced or discontinued varies with every patient, so some claims processing systems cannot automatically process claims with -52 or -53 modifiers. Plus, guidelines issued by the Baltimore-based Health Care Financing Administration (HCFA), the department which manages Medicare, require payers to manually review all claims with modifiers -52 and -53.

Understanding Modifier -53 Key to Getting Paid

Cindy Parman, CPC, CPC-H, principal and co-founder of Coding Strategies Inc., in Dallas, GA, a coding and reimbursement consulting firm, explains that modifier -53 indicates the physician could not complete the procedure because the patient had a problem. The CPT clearly defines -53 as a stopped or terminated service, adds Witt. Discontinued means stopped, whether the patient was in surgery or whether you had her in the stirrups in your office. Its when everything comes to a grinding halt and nothing else is done to that patient, Witt describes.

Modifier -53 is for circumstances in which a diagnostic or surgical procedure is terminated because of circumstances that threaten the well-being of the patient, she emphasizes. This isnt for the patient who says half way through the procedure, Oops, I dont want to do this
now. There has to be a situation affecting the well-being of the patient, for example, her blood pressure dropped or she started bleeding dramatically, so you had to stop, Witt says.

A common mistake coders and ob-gyns make involving modifier -53 is they think it only refers to procedures performed in an operating room. What causes the error is misinterpretation of a note in the CPT definition of modifier -53, which says: This modifier is not used to report the elective cancellation of a procedure prior to the patients anesthesia induction and/or surgical preparation in the operating suite.

The code is telling you that you cant use the discontinued procedure code if theres an elective cancellation before the patient has had any anesthesia, or before surgical preparation in the operating suite. Remember that an operating suite can be a doctors office. It doesnt have to be the operating room in the hospital. The definition doesnt say operating room. It says you either induced anesthesia, or you did your operative scrub or prep. You have to prep a patient in an office for a surgical procedure just as you would in an operating room, Witt maintains. Additionally, the words anesthesia induction are often misconstrued to only mean general anesthesia, which is not the case, she adds.

Applications of Modifier -52

Modifier -52, on the other hand, has two functions, says Witt, one indicating a reduced service and the other indicating a failed procedure. For example, if a physician performed a total abdominal hysterectomy, but elected not to perform the vaginectomy portion of the surgery (as described in CPT), then a -52 modifier would be appropriate to append to the procedure code 58200 (total abdominal hysterectomy, including partial vaginectomy, with para-aortic and pelvic lymph node sampling, with or without removal of tube[s], with or without removal of ovary[s]). This modifier means the doctor elected, for some reason, not to do something that is actually described in the CPT definition being reported, she says.

A -52 modifier also can be appended to a global obstetric code (59400) if, for example, the physician only saw the patient six times (the global package describes 13 antepartum visits), but was the only doctor caring for her pregnancy, and did the delivery and postpartum care. In such a case, Witt continues, a -52 modifier appended to a global obstetric code tells the payer that the physician didnt provide all the care included in the service package as described in CPT. It says, I really didnt do everything that should have been done in the package. I did substantially fewer antepartum visits than normally would have been included, she explains.

The second use of a -52 modifier is for a failed procedure, explains Witt. Lets say youre trying to do an endometrial biopsy (58100*), but you dont succeed, and you try and try but, because of the stenotic cervix, you go on and do a dilation and curettage. The point is you did not complete the initial procedure and because you didnt finish it, you went on and did something else. From a literal coding standpoint, a reduced service was performed when you could not complete the endometrial sampling because of cervical stenosis, and then had to do a regular D&C, she describes. In such a case, accurate coding would be to bill the higher level procedure, 58120 (dilation and curettage, diagnostic and/or therapeutic [nonobstetrical]), along with 58100* (endometrial sampling [biopsy] with or without endocervical sampling [biopsy], without cervical dilation, and method [separate procedure]) and the -52 modifier attached to 58100*, indicating the endometrial biopsy was begun, but not completed.

Although the -52 modifier appended to the 58100* in the above example would be correct coding in theory, in actual practice such a claim may not be paid, experts agree. The fact still remains that many payers do not recognize some or all modifiers, or have their own rules on how to bill reduced services and discontinued procedures.

In many instances, what coders are dealing with is correct coding versus what the insurance will pay for, says Jennifer Jones, a consultant with Practice Management Consulting Corp. in Highland Park, IL. What the insurance carrier would probably say is, Forget the things you were not able to accomplish. Were only going to pay you for the things that were completed, Jones says. She advises ob-gyn practices to obtain a current provider manual from each insurance carrier to check for any policies about reduced services and, when in doubt, contact the carrier for direction. Then, if direction is given verbally, also get it in writing as a safeguard.

Note: Dont confuse modifiers -52 and -53 with -73 (discontinued outpatient hospital/ambulatory surgery center [ASC] procedure prior to the administration of anesthesia) and -74 (discontinued outpatient hospital/ambulatory surgery center [ASC] procedure after administration of anesthesia.) Modifiers -73 and -74 are approved for ASC and hospital outpatient use only, not for physician practices.

Four Easy Billing Tips to Decrease Denials

The following are some billing tips concerning modifiers -52 and -53:

1. Dont file modifier -53 claims electronically. Because modifier -53 involves varying circumstances, payers will usually manually review them. Theres no use in sending claims with this modifier electronically, because the carriers system will probably automatically kick them out for manual review anywayjust slowing down your payment. Instead, send them in right away on hard copy, suggests Jones. The -52 modifier can be submitted electronically, or by hard copy, depending upon the special circumstances surrounding the claim, the judgment of the coder, and requirements of the payer, Jones says.

2. Provide detailed, accurate, easily understandable documentation. Because codes with -53 modifiers attached will be manually reviewed, ob-gyn practices need to recognize that its unlikely the reviewer will be a clinician, and the documentation provided should be in language a layman can understand. For example, with a claim containing a -53 modifier, Jones recommends submitting the paper claim, the operative report, and a special summary report. This special report should describe the patients condition, what the planned procedure was, what the extenuating circumstances were, what actually happened because of the patients condition, and what time and effort was involved, Jones suggests. Put the special report on top of the operative report. The special report should be no longer than a two-paragraph summary. The first paragraph should summarize medical necessity (for example, how sick the patient was) and the second paragraph should summarize the procedure that was planned and why it was discontinued. The extenuating circumstances definitely need to be documented, she advises. If the reviewer wants a more clinical description, he or she can examine the operative report attached, Jones notes.

With the reduced services modifier (-52), Parman recommends ob-gyns dictate in their operative notes how much of the service or procedure they had planned to render was actually completed, and do so in terms of a percentage. The idea is to give the payer a guide to what might be appropriate reimbursement, especially when a service is reduced. If youre going to bill for a lesser service, at the end of the report, make sure you dictate in it that you performed X percentage of what normally occurs during the procedure. The insurance company then should pay you pretty much what youve asked for, Jones says.

Failing to indicate how much of a service or procedure was actually rendered puts the determination of how much care was givenand how much reimbursement you should receiveat the discretion of the reviewer, who may not understand exactly how much of a procedure or service was performed from the clinical description in the operative note. Then, the carrier has the leeway to pay you whatever they want to, and youll have a hard time going back and arguing with them because they are not clinical people. They cant read the operative report and know, for example, that you performed half of an entire procedure, says Parman.

3. Physicians should document. Physicians often are concerned about documenting mistakes, such as puncturing the colon during a gynecologic laparoscopic procedure, because they fear it will become evidence against them in a malpractice lawsuit, Parman says. But to be appropriately reimbursed when extenuating circumstances occur requires stellar documentation, she observes. A lot of doctors are afraid when something goes wrong, which is often the case when a -53 is used, to write it down. When I teach documentation, I tell them they should write everything down objectively, giving all the facts. Everything needs to be recorded, so the physician can justify that he or she really did perform a billable event and deserved to get some money for the actual extent of it. Also, from a malpractice standpoint, its good business practice to document everything (good or bad). You dont ever want to say that you did something really bad, but you do want to document the facts of what happened. Stating the colon was perforated does not admit guilt, but states a fact that it happened, she adds.

4. Dont confuse reduced services with reduced charges. Parman recommends that ob-gyn practices not reduce their fees themselves when filing a claim containing a -52 modifier. This is because reviewers often will see the modifier, and automatically reduce the fee reported. So, if youve already reduced it, the insurance company will probably further discount the fee. When youre submitting a claim with a -52 modifier on it, youre telling the insurer this isnt my average service. This is less of a service than I would normally perform. So, dont cut your fee and bill a -52, she says. The documentation you supply will help guide the payer in determining how much it will reimburse, she notes. When in doubt on exactly how to bill, contact the payer and ask for help.

5. If there is a CPT code that describes the services you actually rendered, use it. Jones points out that modifier -52 for reduced services is to be used only when another existing CPT code does not completely describe what services were given, or what procedure was performed. A -52 would be a case where you look in the CPT book and you see a code that includes W, X, Y and Z, for example. Lets say the doctor didnt do Z, but did do W, X and Y. When there is no code in the CPT book for W, X and Y, then you would bill the code for W, X, Y and Z with a -52 attached to indicate one of the components wasnt done. But, lets say there was a CPT code for W, X and Y. Then, you would use that one, says Jones.

Parman recommends avoiding the -52 and -53 modifiers if possible. If theres another CPT code that describes the service youve rendered exactly, then dont bill the higher level service with a modifier. Bill the one that exactly describes what youve done, she says."