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Be prepared for documentation of reduced/discontinued procedures

HIM Connection, March 28, 2003

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Dear Colleagues:

Modifier -52 (reduced services) is used in those situations where modifier -73 or modifier -74 would have been appropriate. Modifiers -73 and -74 (discontinued surgical procedures) apply only to surgical (10040 - 69990) and certain diagnostic procedures (CPT medicine codes 9XXXX).

In addition, modifiers -52, -73, -74 require that the documentation in the medical record clearly indicate the procedure that the surgeon attempted to perform. Without this information coders may be at a loss for the appropriate code assignment.

For example, one operative report had no clear indication as to the type of surgical technique that was going to be used to repair the patient's rotator cuff tear. There are four codes available:

• 23410: Repair of ruptured musculotendinous cuff (e.g., rotator cuff); acute
• 23412: Repair of ruptured musculotendinous cuff (e.g., rotator cuff); chronic
• 23415: Coracoacromial ligament release , with or without acromioplasty
• 23420: Repair of complete shoulder (rotator) cuff avulsion, chronic (includes acromioplasty)

Without clear indication somewhere in the medical record of the exact technique to be performed for this surgical procedure, the coder will be at a loss as how to identify the correct codes. It is critical when a case like this occurs that the coder look at any available documentation to identify or confirm the surgical technique used when performing the procedure. This might include:

• consent form
• anesthesia record
• progress notes
• appropriate medical record documentation

The above information is critical to assigning the appropriate codes to the intended procedure and appending the -52, -73, or -74 to the intended code.

Additionally, develop and implement internal policies and procedures that specify the level of documentation needed for reduced/discontinued procedures. This is particularly important for departments such as radiology and interventional radiology, where the physicians traditionally, have not written or dictated a note when a procedure is reduced/discontinued.

This week's HIM Connection was adapted from the book "The Modifier Clinic: A Guide to Hospital Outpatient Issues." This new book reviews Medicare's official guidelines for reporting modifiers on outpatient claims. It addresses operational issues associated with modifier reporting using practical exercises, case studies, and detailed figures. There is also a dedicated question and answer section. The author, Lolita Jones, RHIA, CCS, is a well-respected leader in the HIM industry. Lolita is an independent consultant specializing in hospital outpatient and ambulatory surgery center (ASC) coding, billing, reimbursement, and operations. She contributes a monthly column on modifiers to Briefings on APCs from HCPro, Inc., and has more than 15 years experience in publishing, training, and auditing. For more information, or to order your copy, click here.

Sincerely,

Kim Raines Managing Editor

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