Urology Coding Alert

Differentiate between modifiers 52 and 53 with these expert tips

When your urologist discontinues a procedure, you're faced with the challenge of coding the service based on what she did accomplish ...quot; turn to modifiers for help getting paid. In practice, there's enough overlap between modifiers 52 and 53 to cause continued confusion on how to apply them. Keep 52 for Unplanned Reductions Modifier 52 (Reduced services) applies when "a service or procedure is partially reduced or eliminated at the physician's discretion," according to CPT's Appendix A, "Modifiers." You should use modifier 52 when "services are less than described by the code," says Pamela J. Biffle, CPC, CCS-P, ACS-DE, director of operations for AAPC e-Learning headquartered in Salt Lake City. "You don't have to plan on services being reduced to use modifier 52. Often the provider may not know until the service has started."

Alternatively: You should append modifier 53 (Discontinued procedure) if the physician elects to terminate a surgical or diagnostic procedure "due to extenuating circumstances or those that threaten the well-being of the patient," according to CPT instructions.

Generally, however, if the physician plans or expects a reduction in services, or if the physician electively cancels the procedure before it's complete, modifier 52 is appropriate.

Example: If a descriptor specifies a bilateral procedure, such as 55845 (Prostatectomy, retropubic radical, with or without nerve sparing; with bilateral pelvic lymphadenectomy ...), but no code describes an equivalent unilateral procedure and the physician provides the service on one side only, modifier 52 is appropriate. In such a case, you must be certain that there is no designated CPT code to describe the lesser procedure. Unexpected Complications Warrant 53 In contrast, if the physician reduces the service due to unexpected complications that place the patient at unacceptable risk, modifier 53 is appropriate. "The 53 modifier is used when the procedure was started and then is reduced because of extenuating circumstances," says Suzan Hvizdash, CPC, physician educator for the University of Pittsburgh and past member of the American Academy of Professional Coders National Advisory Board. That is, the physician intended to provide the complete service but--because of unusual or complicating circumstances threatening the patient's well-being--he was unable to do so.

For example, a urologist providing a surgical service may abandon the procedure due to extensive hemorrhaging or adverse reaction to anesthesia. In this case, modifier 53 is appropriate.

In another scenario, the physician elected to stop the service because of an uncooperative patient, not because of any undue risk of harm to the patient. Therefore, modifier 52 is more appropriate than 53.

Caution: You cannot use modifier 53 unless anesthesia has already been initiated, Biffle says. If the physician cancels a procedure prior to anesthesia, you cannot bill the [...]