When choosing between modifier 52 and modifier 53, ask yourself, "Why did the provider not complete the procedure or service?"
When deciding between CPT® modifiers 52 Reduced services and 53 Discontinued services, ask yourself, "Why did the provider not complete the procedure or service?"
For modifier 52, CPT® Appendix A explains:
"Under certain circumstances a service or procedure is partially reduced or eliminated 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, signifying that the service is reduced."
In other words, modifier 52 applies when the provider chooses to cancel a service prior to completion or to provide a reduced service. For instance, if the provider plans all along to provide a "lesser" procedure or service, which no other CPT® code better describes, modifier 52 applies. Similarly, you would call on modifier 52 if the provider electively cancels a procedure or service prior to completion.
CPT Assistant (Jan. 2015) provides the following Q&A to demonstrate valid application of modifier 52:
Question: The descriptor of code 38572 reads, "Laparoscopy, surgical; with bilateral total pelvic lymphadenectomy and peri-aortic lymph node sampling (biopsy), single or multiple." Would we append modifier 52, Reduced services, to code 38572 when all nodes are removed except the internal iliac nodes?
Answer: Yes. It would be appropriate to append modifier 52 to code 38572 when reporting the removal of all nodes except the internal iliac nodes.
Modifier 53 applies if the provider quits a procedure because the patient is at risk. In other words, the provider does not so much choose to discontinue the procedure, as sound medical practice compels him or her to do so.
Appendix A of CPT® clarifies:
"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. This circumstance may be reported by adding the modifier 53 to the code reported by the physician for the discontinued procedure."
Documentation should support the decision to append either modifier 52 or modifier 53.
CPT Assistant (December 2007) provides an example:
Question: How would phenol injections to the superior hypogastric plexus be reported when, following multiple-needle positioning attempts at the right and left L5 region, the procedure is discontinued due to the patient's increased heart rate and suboptimal dye spread?
Answer: Code 64681, Destruction by neurolytic agent, with or without radiologic monitoring; superior hypogastric plexus, should be reported once with modifier 53, Discontinued procedure, appended. Modifier 53 indicates that due to extenuating circumstances or those that threaten the well-being of the patient, the physician elected to terminate a procedure.
Payers may not require that you include supporting documentation, initially; but you should be prepared to defend (or, if necessary) appeal your claim, should payment be denied.
Allow the payer to determine payment based on your documentation. As such, it's important to note the effort involved in the discontinued or reduced service or procedure, versus a "typical" case. Do not lower your fees when submitting a claim with modifier 52 or modifier 53 (the payer may reduce the fee, further).
Coding for colonoscopy
For Medicare beneficiaries in the office setting, if a provider preps a patient for a screening colonoscopy but cannot advance the scope past the splenic flexure due to obstruction, patient discomfort, or other complications, append modifier 53 to the appropriate code, per CMS Program Memorandum Transmittal AB-03-114, Change Request 2822. The Transmittal stresses, "Medicare would expect the provider to maintain adequate information in the patient's medical record in case it is needed by the contractor to document the incomplete procedure."
The CPT® codebook, in contrast to CMS rules, instructs, "For an incomplete colonoscopy, with full preparation for a colonoscopy, use a colonoscopy code with the modifier 52 and provide documentation." Some non-Medicare payers may follow CMS guidelines for an incomplete colonoscopy, while others may adhere to CPT® instructions; check with individual third-party payers for their recommendations.