Practice Management Alert

But modifier 53 is best when the doctor stops a procedure for medical reasons

Every time a biller considers appending modifier 52 (Reduced services) to a claim, he knows it could result in lesser payment. However, when a biller does not use modifier 52 and the situation calls for it, the claim could be denied altogether.

Best bet: Recognize all reduced services claims, and be sure to use modifier 52 when appropriate. Check out this advice on billing for reduced services.

The basics: Modifier 52 is for -reporting services that were partially reduced or eliminated at the physician's election. It indicates that a procedure or service is being performed at a lesser service level,- says Mary Falbo, MBA, CPC, president of Millennium Healthcare Consulting Inc. in Lansdale, Pa.

Billers should append modifier 52 to codes for procedures that accomplish some result but don't fully complete the requirements of the procedure's description, says Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, senior instructor and director with the CRN Institute in Egg Harbor, N.J.

Consider this example, courtesy of Falbo: An ob-gyn physician conducts an endometrial biopsy on a patient but is unable to complete the procedure due to the patient's cervical stenosis. On the claim, you should:

- bill 58100 (Endometrial sampling [biopsy] with or without endocervical sampling [biopsy], without cervical dilation, any method [separate procedure]) for the biopsy.

- attach modifier 52 to 58100 to show that the physician reduced the procedure.

- attach ICD-9 code 622.4 (Stricture and stenosis of cervix) to 58100 to represent the cervical stenosis.

- include documentation -explaining the circumstances surrounding the reduction of service,- Falbo says.

Tip: Include a cover letter that describes the reduced procedure and explains the reasons for the reduction, Jandroep says. Your cover letter should include an approximation of how much of the procedure you performed (such as 80 percent) to help the claims reviewer determine the value of your services. Your claims reviewer may not be an expert in your specialty, so use plain language to clearly show the work that deserves payment.

If Doctor Has to Stop Mid-Procedure, Use 53 
 
Remember not to confuse modifier 52 with 53 (Discontinued procedure). Use modifier 53 -when a procedure was actually started but had to be discontinued before completion,- Falbo says. Billers might use modifier 53 when the physician stops a procedure due to extenuating circumstances or conditions that threaten the well-being of the patient.

Example: A patient presents to the hospital for a surgical hysteroscopy with polypectomy. During the procedure, the patient suffers a severe blood pressure drop. The physician, not wanting to risk any harm to the patient, discontinues the procedure. In this example, Falbo says you should:

- bill 58558 (Hysteroscopy, surgical; with sampling [biopsy] of endometrium and/or polypectomy, with or without D&C) for the hysteroscopy.

- attach modifier 53 to 58558 to show that you are billing for a discontinued procedure.

- attach documentation that explains the circumstances surrounding the discontinued procedure.