Modifier 52 vs. 53

December 29th, 2015 - Seth Canterbury, CPC, ACS-EM
Categories:   Coding   CPT® Coding   Modifiers   Surgical Billing & Coding  
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So you’ve read the descriptions for both Modifiers 52 and 53, but you’re still on the fence as to which one is appropriate for a certain surgical case. This brief article will try to better differentiate between these two often-confused modifiers.
 
Modifier 53 is appropriate when a procedure is discontinued due to “an extenuating circumstance or one that threatens the well-being of the patient,” and this physician decision always happens after the procedure has begun in cases where Modifier 53 is appropriate. Often times the decision is made so early in the procedure that only an initial incision has been made but no specific work (as stated in the description of the code that was to have been used) has been accomplished. A re-scheduling of the entire procedure will often be necessary once the reason for the termination is evaluated and resolved, as the original reason for the surgery still exists and still needs surgical treatment.
 
Modifier 52 is used when a physician elects to partially reduce or eliminate a procedure, often (but not always) making this decision before the procedure has even begun. However, something (usually the majority of the work included in the description of the code) is still accomplished in situations where Modifier 52 is appropriate. In some cases, performance of the “reduced” or “eliminated” portion may be done at a later surgery. In other cases, this omitted portion of the service will not be performed at a subsequent operation. Performance of the omitted portion may not be possible because the structure is no longer present (was previously excised) or it is not simply not medically necessary to do this portion of the service.
 
Here’s where it can get a bit confusing: It is possible that a decision could be made by the physician mid-procedure, after doing the majority of the work described by a code, to “eliminate” what was to have been the final part or a procedure, essentially “discontinuing” a surgery before accomplishing all of the work listed in the code description, and this is where some question whether Modifier 53 should appropriately be reported instead of 52. However, a physician electing to eliminate the last portion of a procedure for a reason other than an extenuating circumstance/one that threatens the well-being of a patient should still be coded with Modifier 52, notwithstanding the fact that this decision to “eliminate” a portion of the service could constitute a “discontinuation” in a certain sense of the word.
 

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