How to Avoid Confusing Modifiers -52 and -53- Published on Wed, Mar 01, 2000
Some general surgery coders
have problems distinguishing between modifiers -52 (reduced services
) and -53 (Discontinued procedure
), in part because the CPT descriptors for both are similar in many ways. There are, however, significant differences between these two modifiers, and by following a simple guideline coders can keep them straight: Modifier -52 should be attached to codes when the surgeon completed the procedure but did not fulfill all of its requirements, and modifier -53 should be used for procedures that are terminated by the surgeon, typically because of the patients condition.
For example, a surgeon would use modifier -52 in a co-surgery situation during which a procedure is performed that includes opening and closing the patient. Because another surgeon performing a separate procedure opened and closed the patient, the first surgeon bills for the procedure with modifier -52 attached, to indicate that the procedure was performed without opening and closing.
Another example in which a surgeon would use modifier -52 correctly would be a bilateral pelvic lymphadenectomy (38571, laparoscopy, surgical; with bilateral total pelvic lymphadenectomy
) performed only on one side. In this instance, the procedure should be coded 38571-52 and submitted with a cover letter to explain why only one side was done.
Modifier -52 is not used for an incomplete procedure, but rather, is used when the physician completed what he or she set out to do but did so performing less than the complete procedure. If the surgeon, for instance, only performed four of six components of the procedure, reporting it without a -52 modifier would be inappropriate, says Barbara Cobuzzi, MBA, CPC, CCS-P,
a coding and reimbursement specialist in Lakewood, N.J.
If you dont do exactly what the code describes, you need to inform the carrier that you didnt do it, which is what modifier -52 does, she says, noting that when it is used appropriately, the surgeon cant be held responsible for not reporting the procedure correctly.
Another, more delicate use of modifier -52 is for procedures that have no established CPT code. In certain situations, instead of using an unlisted procedure code, surgeons may prefer to use the code of a similar, but more encompassing listed procedure and attach modifier -52 to it, Cobuzzi says.
Using the -52 modifier in this manner, however, can be dicey. If CPT, Medicare or your private carrier instructs you to use an unlisted code, attaching modifier -52 to a more complex procedure in this manner would be inappropriate, says Susan Callaway-Stradley, CPC, CCS-P,
an independent coding consultant and educator in North Augusta, S.C. Anytime modifier -52 is billed out, make sure your documentation supports the claim. Many carriers want to see the documentation before they consider reimbursing [...]