Coder's Cranium / modifier 52 / modifier 53

Modifiers 52 or 53? Prevent Denials By Making The Correct Choice

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...

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February 17, 2011
Audit / E/M / Provider News

History of Present Illness Must Be Taken by MD, NPP

Don’t let nurses do the doctor’s work, or risk downcoded E/Ms upon audit.

The only parts of the E/M visit that an RN can document independently are the Review of Systems (ROS), Past, Family, and Social History (PFSH) and Vital Signs, according to a June 4, 2010 Frequently Asked Questions (FAQ) answer from Palmetto GBA, Part B carrier for Ohio. The physician or mid-level provider must review those three areas and write a statement that the documentation is correct or add to it.

Only the physician or non-physician practitioner who conducts the E/M service can perform the History of Present Illness (HPI),  Palmetto says.

Exception: In some cases, an office or Emergency Department triage nurse can document “pertinent information” regarding the Chief Complaint or HPI, Palmetto says. But you should treat those notes as “preliminary information.” The doctor providing the E/M service must “document that he or she explored the HPI in more detail,” Palmetto explains.

Other payers have expanded on Palmetto’s announcement, letting physicians know that they cannot simply initial the nurse’s documentation. For example, Noridian Medicare publishes a policy that states, “Reviewing information obtained by ancillary staff and writing a declarative sentence does not suffice for the history of present illness (HPI). An example of unacceptable HPI documentation would be ‘I have reviewed the HPI and agree with above.’”

Good news: Thanks to this clarification, your doctor won’t have to repeat the triage nurse’s work. Right now, if the nurse writes “knee pain x 4 days,” at the top of the note, some auditors might insist that your doctor needs to write “knee pain x 4 days” in his/her own handwriting underneath. But that requirement is a thing of the past if your carrier echoes Palmetto’s requirement.

Bad news: Now this carrier has made it...

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September 16, 2010
CMS / Hot Coding Topics / ICD-9

CMS Announces Over 100 New ICD9 Codes, Effective Oct. 1

Get ready for the dawn of new jaw pain, BMI codes, among others.

If you’ve got high hopes that you’ll benefit from many new ICD-9 codes starting this fall, CMS delivers, with over 130 new diagnosis codes debuting on Oct....

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May 5, 2010