Medicare Compliance & Reimbursement - 2015 Issue 2
Modifiers:Correctly Choose Modifier 52 or 53 -- Every Time
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Article Overview
This article covers how to recognize and document procedures that are reduced or stopped before completion, with a focus on CPT modifier selection and documentation considerations. It is intended for coders, billers, and practice staff who need to understand the general circumstances where procedure completion issues affect code reporting. The discussion also references payer and CMS guidance at a high level and includes procedure examples from endoscopy and hernia repair.
Why This Topic Matters
Accurate handling of reduced or discontinued procedures helps support correct claim reporting, clearer operative documentation, and appropriate communication to payers when a procedure does not proceed as originally planned.
Article Sections
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Use 52 for 'Lessened' Procedures
Discusses situations where a procedure is performed in a reduced form and the general considerations for selecting between the reported procedure and an alternate code. The section also includes an endoscopy example illustrating partial completion of a service.
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Tackle Terminated Procedures with 53
Covers situations where a procedure is stopped before completion and discusses the general circumstances associated with discontinued services. The section includes an example involving a surgical procedure that is ended during the case.
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Check Note for Complete Details
Reviews the importance of documentation when a procedure is reduced or discontinued and notes the need for records that explain why the service ended.
What You Will Learn
- How reduced procedures differ from discontinued procedures at a high level
- Why alternate code selection may sometimes be considered instead of a modifier
- What types of documentation are generally needed when a procedure is not completed
- How payer and CMS references relate to procedure-ending circumstances
Who Should Read This
- Professional coders
- Medical billers
- Physician practice staff
- Revenue cycle staff
Codes Discussed
Modifiers Discussed
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