# Poor Prep Colon



## Tara0513

Here is my dilemma... I have always been under the assumption that during a colonoscopy if the physician reaches the cecum regardless if the prep was poor or not, it is considered a complete colonoscopy:

 "The procedure, indications, preparation and potential complications were explained to the patient, who indicated understanding and signed the corresponding consent forms. Diagnostic type colonoscopy.  IV anesthesia Continuous pulse oximetry, blood pressure, and cardiac monitoring was done. Supplemental oxygen was used. The quality of preparation was good. Patient was placed in left lateral decubitus position. Following a digital exam, the colonoscope was introduced through rectum and advanced under direct visualization until cecum and terminal ileum was reached The cecal sling folds were seen. The appendiceal orifice and the ileo-cecal valve were identified. The colonoscope was retroflexed within the rectum. Careful visualization was performed as the instrument was withdrawn. Patient tolerance to procedure was good. The procedure was difficult due to poor prep and vegetable matter. Digital exam was normal with the following findings: hemorrhoids. The colonoscope was withdrawn and the procedure was terminated due to scope clogging..  A time out to confirm patient's name, status, planned procedure and physicians involved was performed with the endoscopy technician, anesthesia provider and endoscopist present prior to beginning the procedure"

Patient is now being brought back in December for another colonoscopy. They have Horizon BCBS of NJ. How should I bill??????


----------



## jadelzno

*"procedure was terminated due to scope clogging"*

Because the doctor terminated the procedure and wants to repeat within a year, we have been billing:

Z53.8 Procedure and treatment not carried out for other reasons

45378 -53 Professional clm
45378 -74 ASC/facility claim 

And in the notes for the claim, I add "procedure was terminated due to poor bowel prep."

My understanding is, if the physician makes it to the cecum, that is just the difference between billing an incomplete coli and a Flex sig. Once the physician goes past the Splenic flexure, it can no longer be billed as a Flex Sig.

I hope this helps.


----------



## Tara0513

Thank you for your answer, but the physician made it all the way to the cecum, and wants to bring the patient back in with a better prep. Do I still use the 53 modifier?


----------



## NETTECE1

Hi, I hope this helps. I had scope training through NAMAS (National Alliance of Medical auditing specialists. I am AAPC and NAMAS certified. The provider would use a modifier 53 since they plan to reschedule. A 52 would be used if they didn't reschedule the procedure. In the comment section for your 45378- be sure to note poor bowel prep. It is still a complete scope but if the provider repeats and doesn't have an explanation for performing 2 in a short time frame you can get a denial for a duplicate or procedure being performed to soon. You will still use the Z code to show it was stopped. 

Mooney CPC, CEMA


----------



## paul.manlimos@lexicode.com

Hi good day, I hope this message finds you well.

the colonoscope was inserted through the anal canal and could be advanced only to mid sigmoid colon due to presence of brown hard stool.  Careful withdrawal was done with retroflexion view of the rectum

im quite confused if I should use 45330 since it reached only sigmoid colon, or still 45378 with appended modifier 53. And I assigned pdx pre-op dx.

Thank you, looking forward for further enlightenment.


----------



## jrmurphy2015

Hi Paul, we have been following the guidance from the AGA and billing 45378 w/ modifier 53.  I copied the reference and the link is below.  Hope this helps.

"If a patient is scheduled for a screening colonoscopy and because of a poor prep the scope cannot be advanced beyond the splenic flexure, do I code the procedure as a flexible sigmoidoscopy? Accordion Toggle
No. Per Medicare guidelines, the procedure should be codes as a colonoscopy with a 53 modifier, which will pay a partial fee and allow you to repeat the procedure within the restricted time period and get full payment for the second procedure. Even if the scope was advanced beyond the splenic flexure, but the visualization was poor and the physician wants to repeat the procedure within the restricted time period, add the 53 modifier.
"



			https://gastro.org/practice-guidance/reimbursement/coding-faq-screening-colonoscopy/#:~:text=For%20commercial%20and%20Medicaid%20patients,decompression%20%5Bseparate%20procedure%5D).


----------



## such78

jrmurphy2015 said:


> Hi Paul, we have been following the guidance from the AGA and billing 45378 w/ modifier 53.  I copied the reference and the link is below.  Hope this helps.
> 
> "If a patient is scheduled for a screening colonoscopy and because of a poor prep the scope cannot be advanced beyond the splenic flexure, do I code the procedure as a flexible sigmoidoscopy? Accordion Toggle
> No. Per Medicare guidelines, the procedure should be codes as a colonoscopy with a 53 modifier, which will pay a partial fee and allow you to repeat the procedure within the restricted time period and get full payment for the second procedure. Even if the scope was advanced beyond the splenic flexure, but the visualization was poor and the physician wants to repeat the procedure within the restricted time period, add the 53 modifier.
> "
> 
> 
> 
> https://gastro.org/practice-guidance/reimbursement/coding-faq-screening-colonoscopy/#:~:text=For%20commercial%20and%20Medicaid%20patients,decompression%20%5Bseparate%20procedure%5D).



Do you use any modifier when the exam is terminated at the cecum , and doctor documented poor preparation and will repeat colonoscopy in 3 to 6 months?


----------



## zcometa

What would happen if the previous procedure stated poor prep but was done by a different provider, so you don't have access to their billing information, and it turns out they didn't put the 53 mod. So, Medicare denies the claim. Has anyone successfully appealed Medicare for the repeat procedure?


----------



## debemrxs4@aol.com

such78 said:


> Do you use any modifier when the exam is terminated at the cecum , and doctor documented poor preparation and will repeat colonoscopy in 3 to 6 months?


I'd also like to know the answer to this question please....can we use dx code Z91.19 (patient's non-compliance with medical regimen? ( I saw someone post on here not too long ago that this code can be used to indicate "poor prep) However, when provider go the way to the cecum, the is consider complete, therefore, when he documents "poor prep" and wants to repeat in 3 to 6 months, we have an issues with denials because of the fact that they "REACH the CECUM" has anyone else had this issue?


----------



## debemrxs4@aol.com

NETTECE1 said:


> Hi, I hope this helps. I had scope training through NAMAS (National Alliance of Medical auditing specialists. I am AAPC and NAMAS certified. The provider would use a modifier 53 since they plan to reschedule. A 52 would be used if they didn't reschedule the procedure. In the comment section for your 45378- be sure to note poor bowel prep. It is still a complete scope but if the provider repeats and doesn't have an explanation for performing 2 in a short time frame you can get a denial for a duplicate or procedure being performed to soon. You will still use the Z code to show it was stopped.
> 
> Mooney CPC, CEMA


Hello, I would love your input if on this question: Would you also use Modifier 53 when the exam is terminated at the cecum and the doctor documented poor prep and will repeat within 3 to 6 months or next available?


----------

