E&M and other Procedures

In a Patient encounter we might perform procedures apart from the regular E&M procedure, in such instances payors would deny the E&M procedure but would pay the additional procedure alone.

Let us take an example of an encounter where a Trigger Point Injection (CPT 20553) is given and an E&M procedure (99213)  is also performed.

The procedure 20553 has an Evaluation component built into its reimbursement, this is the reason why payors may deny the payment for the E&M procedure. So the Payors are right in denying the E&M procedure if the E&M procedure is not distinct and not separately identifiable from the other procedure performed.
 
But We are definitely allowed to bill a Procedure (20553)  and a distinct E&M service (99213) on the same visit, as long as the E&M service is separate and distinct from the procedure, and the same is documented in the progress notes. A distinct E&M service refers to an evaluation where the service is significant and separately identifiable from the other procedure.

An example would be :  

20553        Trigger point Inj                                 
99213 - 25  E&M service for  HTN, DM, CAD   
 
Here the E&M service is separate and distinct from the Procedure 20553, the E&M service needs to be submitted with modifier 25 to indicate that it is separate from the other procedure performed. If the E&M service is submitted without the 25 modifier, it would be denied.

Modifiers 52 & 53

The usage of Modifiers 52 & 53 is very clear and straightforward but still many claims have these modifiers applied incorrectly opening up the possibility of a recoupment later on.

52 Modifier - Reduced Services.

In many instances a procedure or service is reduced at the discretion of  a physician.

We need to apply the 52 modifier to that CPT code, when the physician is performing a reduced procedure rather than the entire procedure, as denoted by the CPT code and when that reduced procedure does not have a specific CPT code for billing. The 52 modifier should not be applied to a CPT code, when the procedure that was planned had to be discontinued / terminated for any reason whatsoever. In these instances we need to use modifier 53 to indicate that the procedure was discontinued.

If the reduced procedure is surgical, the claim needs to submitted with an Operative report and a separate report detailing how the reduced procedure differs from the normal procedure.

For procedures that are non-surgical, a report detailing how the reduced procedure differs from the normal procedure needs to be sent alongwith the claim.

Example :

The provider is planning on performing pure tone audiometry, air only, for a patient on only one ear. There is no CPT code for this test when performed on one ear, while we have CPT code 92552 pure tone audiometry (threshold), air only, for both ears ( bilateral procedure ). 

In this instance since the provider plans to perform the test for one ear only, this becomes a reduced procedure. Hence we need to append modifier 52 to CPT code 92552.

53 Modifier - Discontinued Procedure.

In many instances a surgical or diagnostic procedure may need to be terminated / discontinued due to various reasons.

A procedure that was initiated may need to be terminated / discontinued due to various reasons, in such cases we need to apply Modifier 53 to the CPT code. A procedure may be discontinued / terminated due to various reasons, such as the patient not being able to tolerate the procedure. The 53 modifier basically indicates that the procedure was initiated but not completed.

If the discontinued procedure is surgical then a Operative report needs to be sent alongwith the claim. 

For procedures that are non-surgical, a report detailing how the discontinued procedure differs from the normal procedure needs to be sent alongwith the claim.

The 53 modifier cannot be used, if a Procedure is discontinued by the Physician before administering anesthesia or surgical preparation in the operating room.

Example :

Colonoscopy was initiated on a patient. Polyps were removed by hot biopsy from the descending colon. The provider then attempted to move the colonoscope past the splenic flexure but due to a tortuous colon / blockage the colonoscope could not advance past the splenic flexure. The procedure was hence discontinued.

In this instance the physician had initiated a Colonoscopy by Hot biopsy CPT 45384, but the procedure was discontinued as the colonoscope could not move past the splenic flexure. Hence we need to append mofifier 53 to CPT code 45384.