Gastroenterology Coding Alert

Find out when you can correctly strike modifier 52 (Reduced services) from a claim to avoid shrinking payment.

Scenario: Your gastroenterologist attempts a colonoscopy on a non-Medicare patient with regional enteritis in the small and large intestines, but the procedure ends at the distal descending colon. Does this count as a reduced procedure?

Solution: Yes -- although you will see some controversy about how you should report a colonoscopy that does not pass the splenic flexure because CPT coding guidelines are not specific on the situation.

You could report 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]) with modifier 52 to show that you are reporting only part of a colonoscopy.

Or, you could report 45330 (Sigmoidoscopy, flexible; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]).

Pay attention: Medicare guidelines differ, and you need to follow published rules. They specify that you should bill an incomplete colonoscopy with modifier 53 appended. The Medicare fee schedule lists a separate payment for 45378 with modifier 53.

Bonus: You should attach 555.2 (Regional enteritis; small intestine with large intestine) to 45378 to prove medical necessity for the procedure.

You should append modifier 52 to codes for procedures that accomplish some result but don't fully complete the requirements of the procedure's description, says Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, CPC-EMS, RCC, CodeRyte coding analyst and coding review teacher.

What to include: Send in documentation with a cover letter that illustrates the reduced procedure to prevent payment delays, Jandroep says.

Your cover letter should include an approximation of how much of the procedure you performed (such as 80 percent) to help the claims reviewer determine the service's value. Your claims reviewer may not be an expert in your specialty, so use plain language to show clearly why the work deserves payment.

Tip: With a modifier like 52, which reduces compensation, don't submit a lower-than-usual fee for the procedure -- leave payment up to the carrier. Submitting a reduced fee could cause the payer to slash your already diminished compensation, Jandroep says.

Don't mix up modifier 52 with modifier 53 (Discontinued procedure) for non-Medicare patients. Use 53 when the physician stops the procedure because continuing would put the patient's health in danger, says Catherine Brink, CMM, CPC, president of Healthcare Resource Management Inc. in Spring Lake, N.J.

You may also distinguish modifiers 52 and 53 by applying this general rule: If the patient received some benefit from the procedure, 52 may be more appropriate. If you don't perform enough of the procedure for the patient to receive any benefit, you'll probably append modifier 53, Jandroep says.

Lesson: Don't automatically append modifier 52 every time your report suggests a service that doesn't quite meet the CPT descriptor. Check for why the physician shortened the procedure and keep track of guidance telling you what services Medicare believes each code represents.

Scenario: Your gastroenterologist performs a diagnostic upper gastrointestinal endoscopy (EGD). He encounters an obstruction while inserting the endoscope and does not progress beyond the esophagus. After several failed attempts at insertion, he decides to stop the procedure in the patient's best interest. Does this count as a reduced procedure?

Solution: No, you should not use 52 for this procedure. Instead report the appropriate esophagoscopy code (43200-43232) and append 53 because the physician stopped out of concern for the patient's well-being. Explain the encounter accurately, giving the carrier the exact reasons the physician stopped the procedure.

You're unlikely to use 52 with an endoscopy, but if the physician begins a diagnostic EGD and decides not to scope the entire tract for reasons unrelated to the patient's health (such as an equipment problem after the scope entered the stomach and before it reached the duodenum), you should append the reduced-services modifier.