Gastroenterology Coding Alert

Find out what your documentation should include

Every time you consider appending modifier 52 (Reduced services) to your gastroenterology claim, you know you could be shrinking your reimbursement. Here's the rundown on when you should -- and shouldn-t -- append 52.

Master Modifier 52 Rules

Rule: 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, CodeRyte Inc. coding analyst and coding review teacher.

Smart: 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 value of your services. Your claims reviewer may not be an expert in your specialty, so use plain language to clearly show the work that deserves payment.

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

Watch Out for Modifier 53 Confusion

Don't confuse modifier 52 with 53 (Discontinued procedure). 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 the two by 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.

Heed Health as Grounds for Halting

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: 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.

Check Colonoscopy Cut-Off Point

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

Solution: Because the colonoscopy does not pass the splenic flexure, you should count this as an incomplete procedure and 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]) for the colonoscopy and append modifier 52 to 45378 to show that you are only reporting part of a colonoscopy.

Remember, Medicare guidelines differ. They specify that you should bill an incomplete colonoscopy with modifier 53 appended. You can find 45378 with modifier53 listed in the Medicare fee schedule.

Bonus: You should attach ICD-9 code 555.2 (Regional enteritis; small intestine with large intestine) to 45378 to prove medical necessity for the procedure.