# Colonoscopy and modifier 52



## coderguy1939

If the doctor is able to advance the scope proximal to the splenic flexure but the prep is so poor as to render the procedure useless (documented in the report) can a modifier 52 be added to the procedure and is there a diagnosis code that can be used to document the problem?


----------



## haadi

YES,

52 will be used, also take V64.3 as a secondary dx if some pathology has been mentioned.

thank you!

Dr.Mohd Ali Hadi  CPC, CPC-H


----------



## FTessaBartels

*How about modifier 53*

NOT my area of expertise ... just a thought ... I seem to recall from years ago coding class ...

How about modifier 53 Discontinued Procedure?

F Tessa Bartels, CPC


----------



## Treetoad

I believe modifier 53 would be used for a medicare patient if there was a medical reason that the procedure needed to be aborted.


----------



## mbort

it also depends on who you are billing for facility or surgeon


----------



## dmaec

my first thought is to use modifier .53.  so I agree with FTessaBartels and Treetoad; 
I don't think .52 would be correct, it's not a "reduced" service - because it really couldn't be done correctly or even partially-  it was a completely discontinued service.

I would code and E/M level however


----------



## scorrado

For Medicare you need to use the -53 modifier. For all other payers (if the dr. has gotten beyond the splenic flexure but has not reached the cecum) you use -52.


----------



## Lisa Bledsoe

-52 Reduced Services - per CPT "under certain cicumstances a service or procedure is *parially reduced or eliminated* at the physician's discretion"

-53 Discontinued Procedure - per CPT "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"

I believe modifier -52 is most appropriate in this scenario.  

Lisa


----------



## coderguy1939

This is facility coding for an ASC so mod. 53 is not available.  Using the description of the procedure, technically the doctor completed the procedure because he reached the cecum.  But the op report states "the visual quality of this examination rendered this evaluation incomplete".  How do you document "suboptimal prep"?


----------



## scorrado

If the doctor is planning on going back in to do the colo because the prep was bad and he could not visualize well,  I would use the -52 since you cant use -53. That way when you bill another colo the insurance knows that the previous one was not "complete".  


For all others who are questioning the use of -53 - Trailblazer (Medicare) has specifically requested that we use that modifier for our patients when the colo is not complete. It may be different for other Medicare carriers but that is what modifier we have to use.


----------



## dmaec

well, if this is Hospital Outpatient then yes - you'd have to use .52 since .53 isn't a choice.

hey Lisa - I have a question maybe you can answer for me - I see what you wrote and it makes sense, but - wouldn't the fact that the provider got "to the splenic flexure but the prep is so poor as to render the procedure useless (documented in the report)" be an *extenuating circumstance*?
Not that it really matters since he can't use mod 53 anyway!~  just looking for your take on that.
thanks!
Donna


----------



## mbort

The 74 modifier is the appropriate modifier for this scenario since it is for an ASC.  (74 is the equal to the 53)


----------



## elenax

I agree with mbort.  The CPT coding book specifically indicates on the description for Modifier 52, 53 to use modifiers 73 or 74 for ASC since those modifiers are approved for hospital outpatient use only .


----------



## Lisa Bledsoe

dmaec said:


> well, if this is Hospital Outpatient then yes - you'd have to use .52 since .53 isn't a choice.
> 
> hey Lisa - I have a question maybe you can answer for me - I see what you wrote and it makes sense, but - wouldn't the fact that the provider got "to the splenic flexure but the prep is so poor as to render the procedure useless (documented in the report)" be an *extenuating circumstance*?
> Not that it really matters since he can't use mod 53 anyway!~  just looking for your take on that.
> thanks!
> Donna



Donna - I sent you a private message so as not to bog down this thread...
Lisa


----------



## amitjoshi4

coderguy1939 said:


> This is facility coding for an ASC so mod. 53 is not available. Using the description of the procedure, technically the doctor completed the procedure because he reached the cecum. But the op report states "the visual quality of this examination rendered this evaluation incomplete". How do you document "suboptimal prep"?


 
Hello All,

Please see the attached article on reduced services. This will give us the clear picture.

*Use of Modifiers 52, 73, and 74 and Anesthesia Reporting under OPPS (page 1)*

Modifiers 52--Reduced services, 73--Discontinued Outpatient Hospital/Ambulatory Surgery Center (ASC) Procedure Prior to the Administration of Anesthesia, and 74--Discontinued OutPatient Hospital/Ambulatory Surgery Center (ASC) Procedure After Administration of Anesthesia, are used to report procedures or services that are reduced or discontinued at the physician's discretion. 
Under the hospital outpatient prospective payment system (OPPS), anesthesia is defined by CMS to include local, regional block(s), moderate sedation/analgesia (conscious sedation), deep sedation/analgesia, and general anesthesia, when services are furnished in the hospital outpatient setting. 
Under certain circumstances, procedures and services provided in the hospital outpatient department and ambulatory surgical center may be discontinued.
Therefore, in the event a procedure or service is discontinued, modifiers 73 and 74 would be appended to the procedure code, in order for the facility to recover any expenses incurred. These modifiers are defined as follows:
·Modifier 73 is used by the facility to report that a patient was prepared for a surgical or diagnostic procedure, which was discontinued prior to the administration of anesthesia. The patient must have been taken to the operating room (e.g., endoscopy suite, gas-trointestinal lab, etc.) and may have received preprocedural medication. If the procedure has been started, append modifier 74. The medical record documentation should reflect the reason for the cancellation. 
·Modifier 74 is used by the facility to report that a patient's surgical or diagnostic procedure was discontinued after the administration of anesthesia or after the procedure was started (e.g., incision made, intubation started, scope inserted). 
·Modifier 52 is used to indicate a partial reduction or discontinuation of procedures and other services that do not require anesthesia. 
Outpatient facilities may also face the task of reporting one or more discontinued or cancelled procedures when multiple procedures are planned. 
a. When one or more planned procedures are completed, report the completed procedures. Any other procedure(s) that were planned, and not started, are not reported.
b. When none of the planned procedures are started and no anesthesia is administered, the first planned procedure is reported with modifier 73. In this instance, the patient must have been prepared and taken to the procedure room.
c. If anesthesia has been administered or the first procedure has been started (e.g., scope inserted, intubation started, incision made, etc.) modifier 74 should be reported with the first procedure. The other procedures are not reported.
d. If the first procedure is terminated prior to the administration of anesthesia and before the patient is taken into the procedure room, the procedure should not be reported.
e. If the first procedure is completed and a second procedure is started but not completed, the second procedure is reported with modifier 74 and the first procedure is reported with no modifier.
Keep in mind that in order to report modifiers 73 or 74, the patient has to be taken to the room where the procedure is to be performed. The following are some examples of how to correctly append modifiers 73 and 74

Hope this will benefit all

Thank You


----------



## pdonohew

*P. Donohew, CPC, CASCC*

Could you tell me where the article you are quoting came from.  I need the written documentation and can not find it.
Thank you


----------



## amitjoshi4

Useful Source is :
http://www.cms.hhs.gov/Transmittals/downloads/R442CP.pdf

Thanks


----------



## elenax

I got the following information from the Gastroenterology Coding Alert Vol 11, No.1:

"Know your way around an* 'Incomplete'* Colonoscopy > The i*ntent *must be to reach the *cecum,* and scope *must pass* the *splenic flexure* to be *complete*."

"*Know your payer*:  Remember, for Medicare and payers that *follow* *Medicare guidelines,* you should *append* modifier *'53'* to 45378 for an *incomplete colonoscopy*.  On the other hand, CPT instructs you to report an incomplete colonoscopy by attaching modifier *52* to the appropiate colonoscopy code (example, 45378).  *So you must* *find out what your payers prefer."*

Also from the* Medicare Claims Processing Manual*:

"Failure to extend beyond the splenic flexure means that a *sigmoidoscopy* rather than a colonoscopy has been performed".

Hope this helps!


----------



## elenax

Replying to your question...The information is for the *Gastroenterology Coding Alert from The Coding Institute 2008 Vol.11, No.1* and I would be more than glad to *fax you a copy* if you provide your *fax number*.


----------

