Mind Your Modifiers When Your Surgeon Works With Others

Posted on 16. Feb, 2009 by Editor in Hot Coding Topics

Automatically appending modifier 52 could be costing you hundreds.

When your surgeon works with another physician during a procedure, you can face major coding challenges. If you don’t coordinate your coding with the other physician’s coder, both doctors could lose money and face audits.

Learn how to correctly code for these shared procedures with this real-world case study.

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Review the Surgical Case

Scenario: A urologist and a general surgeon performed surgery on a patient. The urologist did the orchiopexy and performed the opening and closing. The general surgeon performed an inguinal hernia repair.

Coding dilemma: Which codes should each physician report, and what modifiers should the coders use, asks Betsie Wilson, CPC, professional fee coordinator and charge capture surgery team lead at University of Washington Physicians in Seattle, who presented this case study.

No Bundle Means Two Codes

CPT and the Correct Coding Initiative (CCI) do not bundle the two procedures together. In fact, if your general surgeon performed both the hernia repair and the orchiopexy without another physician, you would report both procedure codes.

For this case study, each physician will report his portion of the procedure. You will report the appropriate inguinal hernia repair code — such as 49500 (Repair initial inguinal hernia, age 6 months to younger than 5 years, with or without hydrocelectomy; reducible) or 49505 (Repair initial inguinal hernia, age 5 years or older; reducible). The urologist’s coder will report the applicable orchiopexy code (54640, Orchiopexy, inguinal approach, with or without hernia repair).

Expert Opinions Diverge on Modifier 52

As for deciding whether to attach modifier 52 (Reduced services) for your general surgeon in this case, you’ll need to talk with the physician and review his documentation.

Some experts say that opening and closing are such a small portion of a procedure that you should not append modifier 52 because the reduction in reimbursement would not be equal to the amount of time and effort the open/closing normally takes. Some coders, however, feel that reporting the code without a modifier isn’t correct coding either.

“I personally don’t add the 52 because the opening and closing are such a minor portion of the procedure that I don’t consider the procedure ‘reduced,’” says Michael A. Ferragamo, MD, FACS, clinical assistant professor at the State University of New York, Stony Brook.

“We have had several cases lately with other surgeons, and I have never thought to append modifier 52 because we didn’t open and/or close,” says Karla D. Garcia, CPC, coder for Dr. West and Dr. Mayo in Paducah, Ky.

Downside: If your payer reduces every case by a third of the regular fee because you append modifier 52 even when your surgeon completes the entire procedure but not the open/close tasks, your practice could be losing hundreds of dollars over the course of a year.

Alternative: Some coders disagree, and say that a surgeon would use modifier 52 in a co-surgery situation where another surgeon performing a separate procedure opened and closed the patient. The rationale is that the first surgeon bills for the procedure with modifier 52…

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Tags: 49500, 49505, 54640, assistant surgeon, co-surgery, hernia repair, modifier 52, modifier 53, modifier 62, modifier 80, orchiopexy