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Modifier 52 and Preventative Medicine Codes

  1. #1
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    Default Modifier 52 and Preventative Medicine Codes
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    Is there any written guidance from CPT that states you can't append modifier 52 to a preventative medicine code?

    Here is the scenario: We have a patient that comes in for her annual physicial. The provider does not take a complete PFSH or a complete ROS. The exam is detailed because the patient did not want here GYN exam performed.

    Can we code this as preventative and append modifier 52? Since preventative codes include a comprehensive exam and a complete PFSH and an extended or complete ROS, and we did not do that here, doesn't this qualify for a reduced service?
    Dawson Ballard, Jr., CPC, CEMC, CPMA, CCS-P, CPC-P, CRHC, AAPC Fellow
    Coder

  2. #2
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    I found this from the AMA regarding this issue:


    From a coding perspective, it would not be appropriate to append Modifier -52 Reduced Services to a Preventive Medicine Evaluation and Management (E/M) Service code when only a brief history and examination is performed. Instead, the appropriate Office or Other Outpatient E/M Service code should be reported based upon the key components that are met (i.e., history, physical exam, medical decision making).

    Now my question....it states that a 52 modifier should not be used if a brief history and exam is performed, but what about as I state above, a detailed history and exam? If the patient presents for his/her annual physicial and only a detailed exam is performed because the patient refused part of it, would you use -52?
    Last edited by dballard2004; 04-08-2010 at 07:53 AM.
    Dawson Ballard, Jr., CPC, CEMC, CPMA, CCS-P, CPC-P, CRHC, AAPC Fellow
    Coder

  3. #3
    Location
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    Default Comprehensive Exam
    You can have a comprehensive exam WITHOUT a GYN exam. Check both 1995 and 1997 guidelines and you'll see it completely possible.

    Additionally, the Preventive Medicine codes do not specify the levels of history, exam, MDM in the same way as for sick visits.

    Most women prefer to have they pelvic exam, etc done by their gynecologist. That does not mean that their internist isn't performing the age-appropriate history, exam, counseling, etc to meet the standards for a preventive visit.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

  4. #4
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    CR 1776 has a section in it on the use of the 52 and it states that it is never appropriate to assign a 52 modifier to any E&M code.

    Debra A. Mitchell, MSPH, CPC-H

  5. #5
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    Thanks so much to both of you! This is helpful.
    Dawson Ballard, Jr., CPC, CEMC, CPMA, CCS-P, CPC-P, CRHC, AAPC Fellow
    Coder

  6. #6
    Wink E/M code with modifier 52
    The info was helpful to me too- However we had a PT come in for visit & needing to schedule further labs & testing- just up & walked out of office- we will probably lose $ on this visit; if this PT continues a pattern of coming in to see DR & not allow us to finish his appt we may have to excuse him from the clinic in the near future- I wanted to see if we could use 52 but from coding standpoint it would not be conventionally correct so I am thinking we will have to choose a low level office visit code in its place.

    Just FYI for future coders who experience this issue.

  7. #7
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    Quote Originally Posted by Jcharbonnet7701 View Post
    The info was helpful to me too- However we had a PT come in for visit & needing to schedule further labs & testing- just up & walked out of office- we will probably lose $ on this visit; if this PT continues a pattern of coming in to see DR & not allow us to finish his appt we may have to excuse him from the clinic in the near future- I wanted to see if we could use 52 but from coding standpoint it would not be conventionally correct so I am thinking we will have to choose a low level office visit code in its place.

    Just FYI for future coders who experience this issue.

    You do not have to PERFORM the additional testing at the visit to get credit for ORDERING the additional testing. If the recommendation was made, whether the patient follows through or not, the provider gets credit for it in the medical decision making.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

  8. Default
    The company I work for wants us to bill the preventive visit 9939x along with modifier 52 if the patient elects not to do her pap at that time because of extenuating circumstances (usually due to menstruation), and then to code the same preventive visit again, along with modifier 52 again, when the patient comes back in her the pap/pelvic exam portion. Would this not be correct?

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