Q: If a surgeon performs a series of laparotomies where they leave the incision open at the end of the case, requiring a return to the OR for a repeat laparotomy, do I need to append modifier 52 to the laparotomy codes? For example, would I code CPT 49000.52 for the first operation where the abdomen was not closed, and then 49002.58.52 for the second surgery since the wound is already open at the beginning of the second procedure, and there is no incision to open the abdomen?
A: While omission of a core element of a procedure clearly requires use of modifier 52 (e.g., a partial colectomy without anastomosis or diversion through an ostomy would require modifier 52), modifier 52 application for omission of opening or closing the surgical incision alone is a gray area in my view.
On one hand, you could argue that the laparotomy service is reduced in staged laparotomies since opening and closing the abdomen is part of the RVUs valued into the codes, and the surgeon did not complete the typical work. However, when deciding whether to apply modifier 52, it is important to review all documentation and to weigh the definition and impact of modifier 52 on the claim to determine if what is described supports a reduced service modifier.
Medicare defines modifier 52 as appropriate for use in cases where the “the service performed was significantly less than usually required.” A link to a Modifier 52 fact sheet from one of the Medicare Administrative Contractors is included here to support that definition: https://www.novitas-solutions.com/webcenter/portal/MedicareJH/pagebyid?contentId=00144533. Based on this definition, insurance companies often reduce the typical reimbursement for a surgery by 50% when modifier 52 is applied, anticipating that “significant reduction” in typical work or intensity of the service. But does the serial laparotomy scenario meet this definition and warrant this kind of reduction? Not always, in my view.
In many cases where definitive, primary closure does not occur, the surgeon is typically closing the abdomen in some manner (e.g., applying temporary dressings or suturing the skin closed without closing all the underlying layers since they will reopen in a day or two when they return the patient to the OR). In these cases, I would argue that there is still surgical work that supports those RVUs for closure and the surgical work is “not significantly reduced.”
Additionally, I have seen cases where a surgeon leaves the patient open, resulting in serial laparotomies, where other aspects of the case could increase complexity. Examples may include extensive lysis of adhesions, an unstable trauma patient who needs a damage control operation now and definitive procedures later, or septic patients that are difficult to manage and stabilize during surgery. In these scenarios, you could almost argue a 22 modifier for increased complexity for some portions of the case. My perspective is that these portions that support increased complexity offset the portion that might warrant reduced services for not formally closing or opening the abdomen.
Finally, when it comes to reopening a recent laparotomy (CPT 49002), we typically assign this code following a recent laparotomy. The lay description for this procedure indicates that the laparotomy site is “opened and re-explored.” Opening and re-exploring could involve removing sutures or staples or dismantling temporary dressings to gain access into the abdominal cavity rather than creating an incision. These alterations to how the surgeon opens the abdomen would be typical in the setting of a recent laparotomy and would not significantly reduce the work or intensity of the service expected for CPT 49002.
With that said, personally, I do not automatically recommend modifier 52 if a formal, primary closure of the abdomen or creation of an incision to reopen the abdomen in the second, staged surgery is the only omitted element for that procedure. Again, I weigh the overall documentation and look for surgical work that might support that the typical work or even increased work for the laparotomy procedure, avoiding use of modifier 52, unless there is a significant reduction in service that warrants the resulting anticipated reduction in reimbursement.
