If you mistake modifiers 52 and 53 as one or the other because they’re both used for incomplete procedures, you’ll end up losing your reimbursement. Remember these two have extremely distinctive functions.
Consider a situation when the gastroenterologist performs an esophagogastroduodenoscopy (EGD) to examine the lining of the esophagus, stomach, and upper duodenum of a patient as part of a GERD evaluation.
Suppose that while inserting the endoscope, the patient registers unstable vital signs. The gastroenterologist, then, decides it is not in the patient’s best interest to continue the procedure. You would report this on your claim using:
- 43235 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]) for the EDG
- Modifier 53 (Discontinued procedure) to show that the GI discontinued the EGD.
Other situations that would call for a discontinued procedure include respiratory distress (786.09), hypoxia (799.02), irregular heart rhythm (427.9), and others usually related to the sedation medications.
Modifier 53 Defined: Under certain circumstances, the physician may elect to terminate a surgical or diagnostic procedure. Due to extenuating circumstances, or those that threaten the well-being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued.
In addition, you shouldn’t disregard the importance of submitting documentation that shows:
- that the physician began the procedure;
- why the procedure was discontinued;
- the percentage of the procedure performed.
Taking on the same scenario, the gastroenterologist begins the diagnostic EGD but stopped without examining the entire upper gastrointestinal tract because she encounters an obstructing lesion in the middle of the stomach. In this case, you should attach modifier 52 to the CPT, says Margaret Lamb, RHIT, CPC, of Great Falls Clinic in Great Falls, Mont.
Modifier 52 Defined: Under certain circumstances, a service or procedure is partially reduced at the physician’s discretion. Under these circumstances, the service provided can be identified by its usual procedure number and the addition of the modifier 52 (Reduced services), signifying that the service is reduced, according to the CPT book, This provides a means of reporting reduced services without disturbing the identification of the basic service.
Other factors from which your gastroenterologist might opt for a reduced service include:
- anatomical variances causing the lumen to be smaller than expected;
- physician’s decision not to complete the procedure for reasons other than the patient’s well being threatened like a poor prep or retained debris obstructing the view.
Do remember that when you submit your claim for modifier 52, you should include detailed documentation similar to the requirements of a modifier 53 claim. Specifically, you should thoroughly explain the encounter to the payer, and be sure to show why the gastroenterologist decided that finishing the procedure was unnecessary.
Offices’ policies vary on whether to reduce physician fees when submitting modifier 52 or 53. While some physicians will reduce submitted fees indicating that the procedure was not completed, others will stick to their regular rates. However, the insurance company always has the last say, so you must recognize that not all insurers treat modifiers the same way. This way, you can work closely with payer representatives to understand the insurer’s approach to modifiers.
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