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 [...]