Expert Leesa A. Israel will take this 60 minute audio session on Tuesday, August 20, 2013, to help you comprehend the meaning of modifiers and when to use them in…
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:
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:
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...
Question: I’m receiving contradictory guidance on which modifier to use when a gastroenterologist does an incomplete colonoscopy. Should I use modifier 52 or 53? Answer: CPT 2011 ends the days of arguing over whether to use modifier 52 or 53 for ...
Remember to describe all the circumstances surrounding a push to get full reimbursement.
Question: If a non-Hodgkin’s lymphoma patient has an adverse reaction to Rituximab less than 15 minutes into the ordered hour-long infusion, should I report a push?
Answer: Experts suggest the most appropriate way to report a discontinued infusion is to append modifier 53 (Discontinued procedure) to the appropriate chemotherapy infusion code, such as 96413 (Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug).
You should use modifier 53 when a physician stops a procedure “due to extenuating circumstances or those that threaten the well-being of the patient,” according to CPT.
Modifier 53 describes an unexpected problem, beyond the physician’s or patient’s control, that necessitates ending the procedure. The physician doesn’t elect to discontinue the procedure as much as he is forced to do so because of the circumstances.
Push: CPT guidelines include “an infusion of 15 minutes or less” as one definition of a push, but 96413-53 describes the ordered and provided service more accurately than a push code (such as 96409, Chemotherapy administration; intravenous, push technique, single or initial substance/drug).
HCPCS: Your documentation should describe the circumstances, the administration start and stop times, and the amount of drug delivered and discarded. If you’re coding for the drug (J9310, Injection, rituximab, 100 mg), you should be able to report the entire amount, assuming you discarded the amount not administered.
ICD-9: Remember also to report the appropriate ICD- 9 codes, such as V58.12 (Encounter for antineoplastic immunotherapy) and 202.8x (Other lymphomas), and a code to indicate why the procedure stopped, such as V64.1 (Surgical or other procedure not carried out because of contraindication) or E933.1 (Drugs, medicinal, and biological substances causing adverse effects in therapeutic use; antineoplastic and immunosuppressive drugs).
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When your urologist ends a procedure early, you know you need to append a modifier to the procedure code, but the challenge is deciding between modifier 52 or...