Modifier 52 vs. 53

Question:

We are confused about the difference between modifier 52 and 53. What is the difference?

Answer:

Modifier 52 Reduced Services is used when the procedure or surgery is partially reduced or eliminated by the physician. This is used when a procedure has an existing CPT code, but not all of the components of the code were performed. Modifier 52 is not used for unlisted procedures (where there is no existing CPT code to describe the procedure that was performed).

Modifier 53 Discontinued Procedure is used when a procedure is discontinued due to extenuating clinical circumstances or those that threaten the well-being of the patient. An example is during a fem-pop bypass a patient develops an arrhythmia and the procedure is discontinued.

*This response is based on the best information available as of 02/04/21.

Excision of Rheumatoid Nodules

Question:

I excised a rheumatoid nodule on both the left and right elbow.  What CPT code do I report?

Answer:

You would report CPT code 24120 (excision or curettage of bone cyst or benign tumor of head or neck of radius or olecranon process).  You can report this procedure when performed bilaterally. Make sure you report the excision on both the right and left elbows with either Modifier 50 or RT, LT depending on what the payor allows.

*This response is based on the best information available as of 2/4/21.

Can I Bill for Fluoroscopy?

Question:

I did a left intraarticular steroid injection in the ASC. I used fluoroscopic guidance. Can I report the Fluoro separately or is it included in the procedure code I used 20610?

Answer:

Yes, you can report fluoroscopic guidance with CPT code 20610. In the ASC make sure you report 77002-26. Modifier 26 is required when you perform guidance in the hospital or ASC when the equipment is owned by the facility.

*This response is based on the best information available as of 01/21/21.

Wedge Excision with Reconstruction

Question:

My physician did a full thickness wedge excision with an Estlander flap of the right upper lip with reconstruction utilizing a cheek flap, adjacent tissue transfer. The defect measures 27 sq. cm. The physician used a mucosal graft from the wedge excised from the lip with reconstruction of the vermillion of the right upper lip. I am not sure what CPT code I should use?

Answer:

You should use CPT code 40525 when the physician removes a full thickness portion of the lip with local flap reconstruction. A “V” incision may be made around the lesion and through the full thickness of the lip. The lesion and surrounding tissues are removed. A local skin flap is incised and advanced to the site of the surgical wound and sutured into place with layered closure.

*This response is based on the best information available as of 12/17/20.

Billing for Reopening of Recent Laparotomy

Question:

Our surgeon insists on billing for 49002 reopening of a recent laparotomy and a 44005 lysis of adhesions, since the case is complicated because the laparotomy was only 60 days ago. Can he bill for both in any circumstance?

Answer:

Although this was a reopening of a recent laparotomy, lysis of adhesions was the primary procedure performed and would be the only code billable. Coding rules would follow the same guidelines for 49002 just as they do for an exploratory laparotomy 49000. When a more extensive procedure is performed, the laparotomy (in this case reopening of a laparotomy) is not separately billable. And don’t forget to add the appropriate modifier depending on the circumstance, to indicate whether the surgery was related, for example a complication, (78), an intentionally staged procedure (58) or if unrelated (79) to the original laparotomy.

*This response is based on the best information available as of 12/03/20.

Coding 23395 for Pectoralis Muscle Repair

Question:

Someone told us to bill 23395 for repairing the pectoralis muscle after removing breast implants. Here’s the common scenario:

• Removal of old bilateral breast implants with capsulectomies
• Repair of pectoralis muscle with re-attachment to chest wall
• Creation of pre-pectoral pocket with acellular dermal matrix
• Placement of bilateral breast implants for reconstruction

What do you think of the recommendation to code 23395?

Answer:

Let’s look at the details. The CPT descriptor for 23395 says “Muscle transfer, any type, shoulder or upper arm; single”. First, are you doing a muscle transfer? No – your scenario says “re-attachment to chest wall” which is not a transfer. Second, are you operating on the shoulder or upper arm? No – your scenario says “breast” and “pectoralis muscle” and “chest wall” which is neither the shoulder or upper arm. Lastly, does your patient scenario look like the typical patient scenario described by CPT? “This is a 35-year-old patient with scapular disability and pain caused by scapular winging undergoes pectoralis major transfer.” No.

Your scenario says “repair” so we ask how the muscle got to a point where it needed to be repaired. The usual scenario is that the surgeon partially detached the muscle to place the implant. Therefore, we do not agree that “repair” of the pectoralis muscle by re-attaching to the chest wall, or putting the muscle back to its original place, would be separately reported. We believe this service is included in whatever code(s) you choose for the breast reconstruction procedure and separately reporting 23395 is not accurate. If there is additional significant work, then you could potentially append modifier 22 to your primary procedure code.

Stay tuned for major CPT code changes to the breast reconstruction codes starting 1/1/21….Kim Pollock will have an upcoming webinar about the changes.

*This response is based on the best information available as of 12/03/20.