Using modifiers correctly to ensure accurate CPT coding

Q: I am confused as to when my billers use modifiers -22, -52, and -53. Can you please help me with the difference between these three modifiers?

A: Several modifiers are used to indicate work done for a patient that does not exactly match the descriptor for the current procedural terminology (CPT) code. Among these are modifiers -22, -52, and -53.

Each CPT code presents a range of work effort and practice expenses required to provide a service. Depending on the amount of work or special circumstances based on the work, reimbursement may be increased or decreased.

Modifier -22

For example, modifier -22 states that when the work required to provide a service is substantially greater than typically required, it may be identified by adding the modifier -22 to the procedure code. It is very important to note that the documentation must support the substantial additional work and the reason for the additional work (e.g., severity of patient’s condition, increased time, intensity, physical and mental effort required.) Since modifier -22 involves additional work, it would be prudent to submit a fee higher than for the same CPT code without -22.

It is also important to state, in the operative note, why the provider feels additional income is justified. In the case of an appeal, the reason for using this modifier must be clearly stated, not inferred. When submitting modifier -22, a higher fee should be reported as more work than the code indicates was performed.

Modifiers -52, -53

There are two modifiers that indicate that the work done was less than the code indicates. When using modifier -52, and -53, submit a lower fee because less work was done.

Modifier -52 states that under certain circumstances, a service or procedure was partially reduced or eliminated at the discretion of the physician or other qualified healthcare professional. If, for example, the patient’s anatomy did not allow the provider to complete the description of the specific CPT code, the modifier -52 would be appended to the procedure code. The reimbursement would be less than under the code without the modifier because less work was done. 

The modifier -53 indicates that the physician or other qualified healthcare professional may elect to terminate a surgical or diagnostic procedure due to extenuating circumstances or those that threaten the well-being of the patient. This modifier should not be used to report the elective cancellation of a procedure prior to the patient’s anesthesia induction and/or surgical preparation in the operating suite.

Modifiers -73, -74

Modifier -73 is used for previously scheduled services performed in the hospital outpatient that are partially reduced or cancelled, either prior to or after administration of anesthesia.

For example, the patient may develop uncontrolled atrial fibrillation after the initial anesthesia induction and the surgeon believes it would be better not to begin the procedure but possibly reschedule it for a later date. Modifier -74 would be used for these circumstances in the outpatient and surgical preparation by the ambulatory surgical center.

The answer to this reader’s question was provided by Maxine Lewis, CMM, CPC, CPC-I, CCS-P, president of Medical Coding & Reimbursement in Cincinnati, Ohio. Send your practice management questions to medec@advanstar.com.