I recently found myself wondering how I should bill for central line that I attempted but was unable to complete. These types of situations do occur, where a physician begins a procedure but is unable to finish it for any number of reasons. In these situations CPT® modifier codes 52 and 53 should be used to indicate the procedure was not completed. How does the book of Current Procedural Terminology (CPT®) define modifiers 52 and 53? I recommend the AMA's CPT 2013 Standard Edition as the definitive resource for CPT® coding.
Modifier 52 Reduced Services: Under certain circumstances, a service or procedure is partially reduced 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. This provides a means of reporting reduced services without disturbing the identification of the basic service. Using this modifier does not reduce the allowance to the provider. Note: Modifier 52 may be used with computerized tomography procedure codes for a limited study or a follow-up studyModifiers 52 and 53 can be used regardless of site of service. You do not have to be in an operating suite to submit CPT® modifiers 52 or 53. When does one use modifier 52? If the physician cannot complete the procedure because of anatomical variances (such as can't get a central line in) or other circumstances or if the physician chooses not to complete the procedure for reasons other than the patient's well being being threatened, use modifier 52
Modifier 53 Discontinued Procedure: 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.
When does one use CPT® modifier 53? When the procedure is aborted due to the patient's well being being threatened, use modifier 53. When submitting payment using modifier 53, be prepared to have documentation showing- The procedure was started
- Why the procedure was discontinued
- The percentage of the procedure performed
What are some examples of when to submit modifier 53?
- Procedure is aborted because of unstable vital signs
- Patient is having a complication of the procedure
- Patient cannot tolerate the procedure
Should you reduce your fees when submitting modifier 52 or 53? That's a decision of the physician and their billing process. Some offices will reduce their submitted fees indicating the procedure was discontinued before completion. Ultimately, you're gonna get paid whatever the insurance company says they're going to pay you and you'll have to go through what ever appeals process they have in place for denial or reductions in claims if you want payment for your services. It's just one more thing to remember in the world of coding. Click here to see all my free lectures on medical E/M billing and coding
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