Mod 52 or 53


Liverpool, NY
Best answers
Patient was scheduled to have Botox injections for overactive bladder. The procedure was started and after the first Botox injection, the dr noticed what appeared to be a raised erythematous region just superior to the ureteral orifice. The patient has a prior history of bladder biopsy after having atypical cytology which was negative for malignancy. The dr was concerned about this abnormal region which had some fisheye-like appearance so he decided to abort the bladder Botox and perform a bladder biopsy on this area. Awaiting pathology results before considering repeat bladder Botox. There is concern that the patient could be harboring some form of bladder cancer.

For the Botox injection, which modifier would be appropriate-52 or 53? I am leaning towards 53 but would appreciate some clarification.

Thank you for any advice.
Thank you for your response.
The Botox was given via cystoscope and the description of 52287 is "injections are made into multiple sites of the bladder." There was only 1 injection done and then the procedure was aborted. So wouldn't this require a modifier since the entire procedure was not completed?
I think it would be fair to bill it without a modifier. The description of it in the CPT book states 'with injection(s)', which would indicate it could be one or it could be multiple.