Gastroenterology Coding Alert

Distinguish incomplete from cancelled procedures -- here's how

When you-re not charging for the full colonoscopy, you have to navigate the modifier maze. Get the skinny on which modifier you should use for which payer, and receive the ethical reimbursement you deserve.

Problem: -When a patient has a colonoscopy and the physician does not reach the cecum but takes a biopsy or does a polypectomy during the course of this procedure, is this procedure considered an incomplete colonoscopy? Which modifier should I use, and does this depend on whether I-m in an office, hospital or ambulatory surgery center?- a subscriber asks.

Hint: An incomplete colonoscopy relies on whether the physician did or did not pass the splenic flexure. What that means: A colic flexure is a bend in the colon. You-ll see two colic flexures in the transverse colon, the longest and most movable part of the colon. The left colic flexure is near the spleen and is known as the splenic flexure.

But the subscriber mentions the cecum. The large intestine begins at the cecum, which is a large pouch below the colic valve that connects to the colon. If your gastroenterologist doesn't get by the splenic flexure, he cannot hope to approach the cecum.

Modifier Depends on Your Payer's Definition

If your patient is on Medicare, you-ve got good insight into which modifier you should use. According to Medicare, a complete colonoscopy examination includes the cecum (and thus, the splenic flexure). If your gastroenterologist performs an incomplete colonoscopy, meaning she doesn't reach the splenic flexure, you-ll use modifier 53 (Discontinued procedure).

However, your modifier will vary with private payers.

Here's why: The colonoscope is a thin, flexible instrument that ranges from 48 inches (121.9 cm) to 72 inches (182.9 cm) long. CPT considers colonoscopies to be complete if the examination passes the splenic flexure, but they typically include the cecum and ileum. A full colonoscopy is typically an exam of more than 60 cm, indicating that you would report this service from the 45378-45392 code range. CPT recommends that when the colonoscopy does not extend past the splenic flexure that you should use modifier 52 (Reduced services). Private payers may take their cue from either CPT or Medicare's payment policies.

Get Advice From Your Peers

Many expert coders agree that you should append only modifier 53 for a non-therapeutic colonoscopy (45378, Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen[s] by brushing or washing, with or without colon decompression [separate procedure]) that does not advance beyond the splenic flexure because they feel that -discontinued- means -stopped.- -In cases where the physician cannot do a complete colonoscopy, we attach modifier 53 to indicate a discontinued service,- says Kelly McClendon, CMC, billing supervisor at Digestive Health Associates PC in Chattanooga, Tenn.

-Modifier 52 is more appropriate when the physician advanced the colonoscope beyond the splenic flexure but aborted due to poor preparation,- says Alka Jhurani, CCS-P, reimbursement analyst and internal medicine specialist at the Medical College of Virginia Hospital in Richmond. -The physician may repeat this procedure.-

How Biopsy Increases Reimbursement Level

Good news: When your physician performs a biopsy or polypectomy, you-ll gain even greater insight about which modifier to use for incomplete colonoscopy procedures.

-Physicians may find a polyp, cancer or area of inflammation in the lower part of the colon (such as the rectum or sigmoid colon) that they need to biopsy and remove,- Jhurani says. In other words, the gastroenterologist may biopsy a polyp found in the sigmoid colon but not be able to advance the scope beyond the ascending colon.

If the physician performs a biopsy or polypectomy, the level of reimbursement will be higher even though the colonoscopy is still incomplete. In the case of a biopsy, you may use 45380 (Colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiple) with modifier 53, McClendon says.

For a polypectomy performed during an incomplete colonoscopy, you should use 45384-45385 (removal of tumors, polyps, or other lesions by various techniques) with the reduced-services modifier 52.

Don't Overlook Location

Where your gastroenterologist performs the procedure can also help determine how you handle a cancellation situation.

In an ambulatory surgery center, report the appropriate procedure code for the case and append modifier 73 (Discontinued outpatient procedure prior to anesthesia administration) or modifier 74 (Discontinued outpatient procedure after anesthesia administration), depending on when the physician canceled the case.