Anesthesia, patient well-being can clue you in to the best modifier choice.
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 53. Learn the very specific criteria for reporting each modifier to ensure successful coding every time.
Turn to 52 for ‘Physician Discretion’
You should use modifier 52 when your urologist, while performing a service or procedure, chooses to partially reduce or eliminate a portion of the code’s requirements.“Under certain circumstances a service or procedure is reduced at the physician’s discretion and this decision can be made prior to or during the procedure,” explains Daniel J. Rogers, practice manager for Gulf South Urology in Biloxi, Miss.
You should use modifier 52 when services your urologist performs are less than those described by the code. For instance, you can use modifier 52 when the urologist performs a service/procedure unilaterally when code specifies “bilateral.” In such a case, you must be certain that there is no designated CPT code to describe the lesser procedure.
Example: Your urologist performs a retropubic radical prostatectomy with nerve sparing and a unilateral pelvic node dissection. Report 55845-52 (Prostatectomy, retropubic radical, with or without nerve sparing; with bilateral pelvic lymphadenectomy …) for the procedure.
Because the code descriptor for 55845 specifies bilateral, and the urologist performed only a unilateral node dissection, you should append modifier 52. You do not have to indicate the side, but that information should be in your urologist’s documentation if the payer requests the documentation.
Tip: Let the payer reduce the fee for the procedure when you use modifier 52. Do not apply the fee reduction on the claim. If you do, the payer may still reduce your reimbursement because of the modifier, and you may then receive a double fee reduction.
Tackle Extenuating Circumstances With 53
You will use modifier 53 when your urologist ends a procedure due to a threat to the patient’s well being or other extenuating circumstances, says Leah Gross, CPC, coding lead at Metro Urology in St. Paul, Minn. For example, if the equipment your urologist is using fails, and he has to discontinue the procedure before completion, append modifier 53 to the procedure code. Note: Equipment failure qualifies as an extenuating circumstance.
Documentation clue: Look at your urologist’s documentation to see if the patient underwent anesthesia. You can only use modifier 53 after anesthesia administration and/or a surgical prep took place, and the procedure was actually started, Gross cautions. CPT “specifically states that the procedure was started but discontinued due to extenuating circumstances. This implies that the patient has been fully prepped and anesthetized for surgery,” Rogers confirms.
Example: Your urologist performs a transurethral resection of the prostate (TURP) but must terminate the procedure before finishing because the patient’s blood pressure drops significantly for an extended period of time. You should report code 52601-53 (Transurethral electrosurgical resection of prostate , including control of postoperative bleeding, complete [vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included]) for the TURP procedure. Just as with modifier 52, you should let the payer reduce the fee on services to which you attach modifier 53. Otherwise, you risk additional payment reductions.
Bottom line: “When reading the operative report of a discontinued service, simply look at the reason for the discontinuance,” Rogers says. “Was it an extenuating circumstance — in which case it would be it would modifier 53? Was it physician discretion? Then it would be modifier 52.”
Facility difference: If you are coding only for facility payment, such as for an ambulatory surgical center (ASC), use modifiers 73 (Discontinued outpatient procedure prior to anesthesia administration) or 74 (Discontinued outpatient procedure after anesthesia administration) instead of 52 and 53, says Nancy Giffin, MA, CPC, CUC, billing manager for five physicians at the Swedish Urology Group in Seattle.
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