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Do not append modifier -52 to procedures involving equipment failure

APCs Weekly Monitor, July 29, 2005

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Do not append modifier -52 to procedures involving equipment failure

QUESTION: I have a question regarding equipment failure. A sleep study test is stopped due to equipment failure. Can we bill the procedure using reduced services modifier -52? Or should we never bill discontinuation of a test due to equipment failure?

The reduced services modifier references a physician's decision to discontinue a test/procedure due to extenuating circumstances. I'm thinking this means patient safety--and not equipment failure--prevents completion. In most cases of equipment failure, physicians rarely make decisions. Typically, the technician administering the test makes the decision.

ANSWER: CMS defines the use of modifier -52 (reduced services that do not require the use of anesthesia) as follows:

A service or procedure may be partially reduced or eliminated at the physician's discretion. If a procedure is not completed in its entirety, bill the procedure with modifier -52. Reimbursement will be based on what is accomplished and priced to a code that reflects the completed portion of the procedure. Documentation including, but not limited to, an operative/procedure report is required to make a determination of payment.

Modifier -52 is typically used to code a limited service. For example, when a patient is intolerant to continuous positive airway pressure and the physician stops a titration polysomnogram before he or she completes six hours of recording, code the procedure 95811-52.

To answer your three questions:

1. Can we append modifier -52 in situations involving equipment failure? Modifier -52 is designed for procedures that are halted due to a patient's condition or response to the procedure/test. While it is important to stop the test for patient safety resulting from equipment failure, this does not mean CMS will reimburse you for the partial test. CMS relies upon the provider to maintain all equipment in good working order. Providers absorb the costs associated with equipment failure.

2. Should we ever bill a test that is discontinued due to equipment failure? No.

3. Does a physician have to be involved in the discontinuation of a test in order to bill it? Any caregiver can stop tests/procedures due to patient reaction. It is assumed that once the physician is made aware of the situation, he or she will concur with stopping the test. The physician does not have to be the one to stop the test to qualify for modifier -52, but he or she must ultimately agree that the test was stopped for medical reasons-not convenience or equipment failure.

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