Modifiers 52: Professional fee-for-service guidelines for modifiers do not apply in the clinical setting.
Reduced, Failed, Aborted, Aborted… which one? What are the requirements for using modifiers 52, 73 and 74?
These questions are common in the coding center world, and the answers never seem to be clear. Confusingly mix up the medical code instructions for charge coding and you’re headed down the rabbit hole. Let’s take a look at the coding requirements for the applicable scenarios and answer once and for all when these modifiers should be used in the requirements center.
Definitions of Modifiers 52, 73 and 7
Let’s start by outlining the fundamental modifier definitions specific to facility criteria, focusing solely on ambulatory surgical centers (ASCs) and outpatient hospital settings. Physician coding should utilize the appropriate physician modifiers.
Modifiers 52:
This modifier 52 signifies a partial reduction, cancellation, or discontinuation of services where anesthesia was not initially intended, or the cessation of radiology procedures and other services not requiring anesthesia.
This modifier 52 is applicable only if anesthesia was neither planned nor administered, even for reduced procedure components.
Modifier 73:
This modifier denotes that the procedure was halted or aborted before the planned administration of anesthesia.
Documentation in the medical records should justify the reason for the cancellation.
Modifier 73 should only be reported if the patient was prepped for the procedure and taken to the designated room for its execution.
Modifier 73 cannot be used if anesthesia wasn’t part of the initial plan for the procedure.
Note: Procedures tagged with modifier 73 will be reimbursed at 50 percent of the applicable fee schedule rate for the facility.
Modifier 74:
This modifier indicates that the procedure was ceased or terminated after anesthesia had been administered as planned.
Similar to modifier 73, the patient should have been prepped and brought to the procedural room for modifier 74 to be applied.
Modifier 74 should not be used if anesthesia wasn’t intended for the procedure initially. Note: Procedures labeled with modifier 74 will be reimbursed at 100 percent of the applicable fee schedule rate for the facility.
These guidelines do not extend to elective cancellations, which are not subject to reporting.
Medical Coding and Billing for Medical Services:
Under Medicare, anesthesia is provided on hospital wards:
- Primary, regional (98)
- General anesthesia
Reduced surgical procedures
No modifiers should be used when surgical procedures are performed with reduced anesthesia but are performed as planned (i.e., primary care without disrupting the presentation).
Note: In this case Modifier 52 is used on the load side but not on the equipment side.
Guidelines in the AHA HCPCS Coding Clinic (2012, vol. 12, no. 1) tell us to use modifier 74, not Modifiers 52, for these conditions. The American Hospital Association updated this guideline to align with AHA HCPCS (2021, Vol. 21, No. 4).
According to the revised guidelines: “…there is no appropriate change in the use of the equipment when the method of distribution is applied as intended.”
In another example, AHA HCPCS Clinical Coding (2021, volume 21 and intended) Limiting examples of the following procedures:
Typically, both procedures were intended to be performed as a single procedure only and no other codes were available for methods such as tonsillectomy.
Internal/external segment hemorrhoidectomy and internal approach hemorrhoidectomy are performed.
Removal and replacement of a part in more than one device.
Failure and Unsuccessful Procedures
Management of appropriate use of variables associated with attempts and failures/failures is different from the deleted/deferred procedure.
AHA HCPCS for Clinical Coding (2016, vol. 16, no. 1): “Assessing a process as ‘failing’ or labeling it as ‘failure’ indicates that the (expected) results from the process were not achieved. Although the method can be described as successful or unsuccessful, these actions have actually been taken and need to be recorded. “
The article further explains: “Sometimes many unsuccessful attempts are made simultaneously to carry out the process, and ultimately the attempt is successful. Failure is considered part of success.”
Examples:
Attempt or failure to reduce fractions or separation.
Failed attempt or failure to perform external cephalic version.
Procedures were interrupted, blocked, or removed.
A procedure was interrupted (i.e. interrupted , cancellation or withdrawal) is when a patient is brought into the medical room for an appointment and a procedure has been initiated but for some reason the procedure has been stopped or not completed. There are many reasons why a procedure may be stopped: the patient changes their mind about the procedure, poor anesthesia behavior, the patient experiences complications such as heavy bleeding, or the doctor discovers a problem after the procedure is stopped. . work had begun.
AHA HCPCS Clinical Coding (2016, Chapter 16 and CPT codes are added to indicate that the procedure or service is stopped or discontinued at the physician’s discretion before or after the administration of anesthesia.)
One article states that the code is required. “In which the process is planned and/or initiated
In which the process is stopped or stopped
In which the process is completed but the desired results are not achieved
Instituting anesthesia in which the process is stopped or stopped before or after”
Based on the information given above, modifier for surgical procedures that are removed before/after anesthesia 73/74 We would choose
Change 73 example:
A 56-year-old patient with an inguinal hernia has an inguinal hernia. The hernia is opened. The patient is taken to the operating room before surgery and the patient’s blood pressure is high before general anesthesia is administered. Because of this investigation, the provider chooses to stop the process.
In this case, enter the correct CPT® code with modifier 73 added.
Example of Change 74:
A patient with the appropriate calculator is shown the cystourethroscopy system, lithotripsy, and stent. The patient is prepared and general anesthesia is applied. Amount included; but the severity is consistent and after a few attempts the provider deletes the instance and stops the process.
In this case, enter the correct CPT® code with modifier 74 added.
Tip: Regarding procedures removed during colonoscopy code review, there are specific guidelines for the best code provided. When colonoscopy is attempted and removed for CPT® code management, code selection will vary depending on whether the provider can advance splendid flexion.
- If you cannot achieve full dilation and ultimately cancel/cancel before reaching the splenic flexure, the sigmoidoscopy code is appropriate.
- If you are unable to complete a full abortion and have an abortion(s) that is not easy, use modifier 74 for the appropriate colonoscopy code.
- If the measurement reaches the cecum, a transducer is not needed.
Multiple Processes – Terminated Process:
Another area where there was some confusion was when multiple processes were spawned and one was terminated. Several conditions must be considered to determine the correct code:
- If multiple procedures are planned but none are performed, only the primary procedure with an appropriate replacement (73 or 74) is reported.
- If one process has finished and the second has started but not finished, code the first process without modifier and report the second process with modifier 74. Other scheduled processes that have not started are not reported.
- Substitution 73 is valid for at most one procedure code experienced by the patient.
- When planning and stopping/stopping a two-way process, only the one-way process (first page) can be reported with switch 73. The second page cannot be reported. Do not report binary change 50 together with change 73 in the same procedure code.