If you mistake modifiers 52 and 53 as one or the other because they’re both used for incomplete procedures, you’ll end up losing your reimbursement. Remember these two have extremely distinctive functions.

Consider a situation when the gastroenterologist performs an esophagogastroduodenoscopy (EGD) to examine the lining of the esophagus, stomach, and upper duodenum of a patient as part of a GERD evaluation.

Suppose that while inserting the endoscope, the patient registers unstable vital signs. The gastroenterologist, then, decides it is not in the patient’s best interest to continue the procedure. You would report this on your claim using:

• 43235 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]) for the EDG
• Modifier 53 (Discontinued procedure) to show that the GI discontinued the EGD.

Other situations that would call for a discontinued procedure include respiratory distress (786.09), hypoxia (799.02), irregular heart rhythm (427.9), and others usually related to the sedation medications.

Modifier 53 Defined: Under certain circumstances, the physician may elect to terminate a surgical or diagnostic procedure. Due to extenuating circumstances, or those that threaten the well-being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued.

In addition, you shouldn’t disregard the importance of submitting documentation that shows:

• that the physician began the procedure;
• why the procedure was discontinued;
• the percentage of the procedure performed.

Taking on the same scenario, the gastroenterologist begins the diagnostic EGD but stopped without examining the entire upper gastrointestinal tract because she encounters an obstructing lesion in the middle of the stomach. In this case, you should attach modifier 52 to the CPT, says Margaret Lamb, RHIT, CPC, of Great Falls Clinic...

If your neurologist or pain specialist administers greater occipital nerve blocks, don’t let coding turn into a headache. Verify specifics about the patient’s headache and the service your provider offered to pinpoint the correct diagnosis and procedure codes every time. Our 4 questions will point you to the best diagnosis and injection codes.

Where Is the Occipital Nerve?

The greater occipital nerve (GON) originates from the posterior medial branch of the C2 spinal nerve and provides sensory innervations to the posterior area of the scalp extending to the top of the head. Physicians typically inject the GON at the level of the superior nuchal line just above the base of the skull for occipital headaches or neck pain.

Some physician practices include a small illustration in the chart that the physician can mark with various injection sites. Including this type of tool helps your physician clearly document the injection location, which helps you choose the correct nerve injection code and submit more accurate claims.

What Type of Headache Does the Patient Have?

Your physician’s documentation might include notes ranging from “occipital headache” to “occipital neuralgia” to “cervicogenic headache.” Your job is to ensure that you interpret the notes and assign the most accurate diagnosis.

Occipital headache: ICD-9’s alphabetic index does not include a specific listing for occipital headache. Because of this, report the general code 784.0 (Headache), which includes “Pain in head NOS.” More details in your provider’s notes might lead to diagnoses such as 307.81 (Tension headache), 339.00 (Cluster headaches), 339.1x (Tension type headache), or 346.xx (Migraine).

Occipital neuralgia: You have a more specific diagnosis to code when your provider documents occipital neuralgia. Greater occipital neuralgia produces an aching, burning, or throbbing pain or a tingling or numbness along the back of the head. You’ll report diagnosis 723.8...