Resolved Can a Hospital Bill Modifier 52 for Facility Side for An Incomplete Colonoscopy

[SharaC_69830]

Can a hospital bill modifier 52 for facility side for an incomplete colonoscopy? I thought it would be 74.

 

[Lori]

Modifier 52​

Partially Reduced or Eliminated Services

Instructions​

This modifier is used to indicate partial reduction, cancellation or discontinuation of services for which anesthesia is not planned. The modifier provides a means for reporting reduced services without disturbing the identification of the basic service. It also identifies a situation where a physician reduces or eliminates a portion of a service or procedure.

Correct Use​

• Indicate statement "reduced services" in Item 19 in CMS-1500 claim form (or electronic equivalent)
  • Include brief reason for reduction
  • Documentation includes complete reduction reason retained in patient's record
• Beginning January 1, 2008, contractors apply a 50 percent payment reduction for discontinued radiology procedures and other procedures that do not require anesthesia
  • Facilities use this modifier to indicate discontinuance of these applicable procedures
  • Continue to use modifiers 73 and 74 for all other types of procedures
• To determine charge amount, reduce normal fee by percentage of service not provided
  • E.g., if 75% of normal service provided, reduce amount billed by 25%
  • Medicare claims processing system reimburses lower of actual charge or fee schedule allowance

52 - JE Part B - Noridian

View modifier definition, instructions, correct/incorrect use, claim example and resources.

med.noridianmedicare.com

Modifier 73 Fact Sheet​

Use modifier 73 to report discontinued outpatient/hospital ambulatory surgical center (ASC) procedure prior to the administration of anesthesia.

Physicians should not use this modifier. This is only appropriate for use by the ASC.

Appropriate Usage​

Due to extenuating circumstances or threaten patient well-being:

Prior to procedure started/patient's surgical preparation (including sedation or taken to procedure room)
Prior to administration of anesthesia (local, regional block or general)

Inappropriate Usage​

Physician cancelled the surgical or diagnostic procedure prior to administration of anesthesia and/or surgical preparation of the patient
Elective cancellation of a procedure
Surgeon cancels or postpones because patient complained of a cold or flu upon intake

Modifier 73 Fact Sheet

www.novitas-solutions.com

Modifier 74​

After Anesthesia Administration - Discontinued Ambulatory Surgical Center (ASC) or Outpatient Hospital

Instructions​

In an Outpatient Hospital, or Ambulatory Surgical Center (ASC) if a procedure has to be terminated, due to unforeseen complications, after anesthesia has been administered use Modifier 74.
Contractors may make full payment for modifier -74 if the following met:

1. Modifier 74 appended to anesthesia or surgical procedures when discontinued
2. AFTER anesthesia administration induced or procedure initiated
3. ASC or outpatient hospital only
4. Due to medical complications, extenuating circumstances, or threat to patient well-being
5. Documentation requirements met

Correct Use​

• Physician may terminate surgical/diagnostic procedure
  • After procedure started (incision made, intubation started, scope inserted)
  • After administration of anesthesia (local, regional block or general)
• Under these circumstances, intended service is prepared, but canceled and billed with usual procedure number

Incorrect Use​

• Do not report elective cancellation of patient service prior to administration of anesthesia and/or surgical preparation
• Physician reporting of discontinued procedure, see modifier 53

74 - JE Part B - Noridian

View modifier definition, instructions, correct/incorrect use, claim example, and resource.

med.noridianmedicare.com

CCO Community Modifier thread:

Resource - CPT Modifiers

CCO Video Modifiers Made Easy: FREE CCO TOOL: https://www.cco.us/cpt-modifier-decision-grid-tool/ 22- Increased Procedural Services 23- Unusual Anesthesia 24- Unrelated Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional During a Postoperative...

www.cco.community

 

[SharaC_69830]

So it would be correct for a hospital to report a discontinued colonoscopy with a 52?
No anesthesia or reduced service for this modifier.

 

[Lori]

Yes.