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Implement policies for documentation of reduced/discontinued procedures

HIM Connection, June 29, 2004

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Use modifier -52 (reduced services) when modifier -73 or modifier -74 are not appropriate because anesthesia was not an inherent part of performing the procedure. Modifier -52 demonstrates that the procedure was discontinued.

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

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

Codes and descriptions

23410: Repair of ruptured musculotendinous cuff (e.g., rotator cuff open); acute

23412: Repair of ruptured musculotendinous cuff (e.g., rotator cuff open); chronic

23415: Coracoacromial ligament release, with or without acromioplasty

23420: Repair of complete shoulder (rotator) cuff avulsion, chronic (includes acromioplasty)

29827: Arthroscopy, shoulder, surgical; with rotator cuff repair

Without clear indication somewhere in the medical record of the exact technique performed for this procedure, you will not know how to identify the correct codes. When these cases occur the coder must look at any available documentation to identify or confirm the surgical technique used when performing the procedure. This might include any of the following:

• Consent form
• Anesthesia record
• Progress notes
• Appropriate medical record documentation

Complete documentation is critical to assigning the appropriate codes to the intended procedure and appending the -52, -73,  or -74 modifier to the intended code.

Develop and implement internal policies and procedures that specify the level of documentation needed for reduced/discontinued procedures. This is particularly important in departments such as radiology and interventional radiology. In these two cases, the physicians traditionally have not written or dictated a note when a procedure is reduced/discontinued after the patient is taken to the room in which the procedure is scheduled to be performed.

This excerpt is adapted from the book The Modifier Clinic: A guide to hospital outpatient issues.

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