Gastroenterology Coding Alert

Search your documentation to see if the colonoscopy passed the splenic flexureFind out when you can correctly strike modifier 52 (Reduced services) from a claim to avoid shrinking payment.Decide When You Need Modifier 52Scenario: 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.Have These Necessities on HandYou 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.Be Wary of Modifier 53Don'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 [...]