Otolaryngology Coding Alert

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answer.   Question: How should I charge for a sleep study (95810) when the patient wants to discontinue the procedure after three hours? Should we still charge the patient?

Indiana Subscriber     Answer: In certain circumstances, otolaryngologists 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 (Reduced services) indicates that a service was reduced or eliminated at the otolaryn-gologist's discretion, according to CPT 2002, Appendix A. Modifier -53 (Discontinued procedure) identifies a procedure that was terminated due to circumstances that create risk for the patient. In your scenario, the patient elected to terminate the procedure, rather than medical necessity requiring the procedure's termination. Therefore, you should report the sleep study (95810, Polysomnography; sleep staging with 4 or more additional parameters of sleep, attended by a technologist) appended with modifier -52. CPT's introduction to sleep testing states, "Report with a -52 modifier if less than 6 hours of recording or in other cases of reduced services as appropriate." So, regardless of whether the patient wants to discontinue the study an hour or five hours into the procedure, modifier -52 appropriately describes an elected termination. Of course, you should document when and why the service was reduced or discontinued. Explain the exact circumstances that led to the decision to reduce or terminate the procedure. Send a cover letter with the claim and the operative note so the payer can make an informed decision on how to adequately price the level and extent of service you provided. Bill the study at full fee, send in the claim with documentation, and let the payer choose the fee.