Less commonly used procedural modifiers that can come in handy

Cracking the Code

Dirk Elston

Dr. Elston, who serves as director of the Ackerman Academy of Dermatopathology in New York, has served on the AMA-CPT Advisory Committee.

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52: Reduced Service

Modifier 52 would be appropriate for procedures where the service or procedure performed was partially reduced or eliminated at the physician’s discretion. This allows the provider of service to report a reduced service without altering the identification of the basic service. The documentation should clearly indicate how the reduced service is different from the standard procedure, regardless of whether the service is a surgical procedure or not. The modifier should not generally be attached to codes that specify a number of lesions “up to” a given number, as they are valued based on a range of services that may be needed. For example, if you treat a single wart, it would not be appropriate to attach modifier 52 to the code 17110.

For reduced services due to extenuating circumstances that threaten the well-being of the patient prior to or after administration of anesthesia, review the use of modifiers 73 and 74.

53: Discontinued Procedure

Modifier 53 is appropriate when a physician has to terminate a surgical or diagnostic procedure because of extenuating circumstances that threaten the well-being of the patient. The supporting documentation should be submitted with the claim to demonstrate what services were performed and why the procedure had to be abandoned. Procedure codes billed with modifier 53 may be subject to carrier review and reimbursement will be determined based on each individual case.

This modifier is not to 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.[pagebreak]

Modifiers 54 and 55

It would be unusual for a dermatologist to report modifiers 54 and 55, as any dermatologist in the same practice group would be considered the same “provider.” However, a solo provider who has to arrange post-operative care with a physician who does not work in the same practice might have occasion to use these codes.

54: Surgical Care Only

Modifier 54 indicates that all or part of the post-operative care is relinquished to a physician who is not a member of the operating physician’s group practice. The modifier should only be used in conjunction with procedural codes that contain significant work on post-operative days (i.e., those with 10- or 90-day global periods). The record should indicate who is providing each portion of the service and why. The Medicare Physician Fee Schedule indicates the reimbursement percentages for each portion of the major and/or minor surgical procedures. Documentation should also include a copy of the written transfer agreement in the medical record.

55: Postoperative Management Only

Modifier 55 would be used by the physician, other than the surgeon who is providing the post-operative care. The date of surgery/service, date the physician assumed and relinquished care in box 19 of the CMS 1500 form or electronic equivalent, and a copy of the written transfer agreement should be documented in the medical record. If you provide the surgical services and a portion of the post-operative services, you would report both modifiers 54 and 55 with a careful explanation of what dates and services you provided and those services rendered by someone else.[pagebreak]

Example 1:

A patient develops a cardiac arrhythmia during a surgical procedure and the procedure has to be abandoned. You report the procedure along with modifier 22.

Incorrect: Modifier 53 is the correct modifier for a discontinued procedure.

Example 2:

You treat 12, rather than 14, molluscum lesions, so you attach modifier 52.

Incorrect: Code 17110 specifies destruction of up to 14 benign lesions. You do not have to attach a modifier if you treat only 12, or any lesser number of lesions.

Example 3:

As a favor to a patient who had scheduling issues, you perform Mohs and an adjacent tissue transfer just before you leave for vacation. Follow-up post-operative visits are planned, but you arrange for these to be done by another practice that covers for you when you are out of town. You report the services with modifier 54.

Correct: The adjacent tissue transfer includes payment for follow-up visits during a 90-day global period. Modifier 54 indicates that all or part of the post-operative care was relinquished to a physician who is not a member of your group practice. The modifier should only be used in conjunction with procedural codes that contain significant work on post-operative days (i.e., those with 10- or 90-day global periods). The record should indicate who provided each portion of the service and why, as well as a copy of the written transfer.


For more information on modifiers and how they can be utilized, see Appendix A in the AMA/CPT coding manual.