Gastroenterology Coding Alert

Forego modifier 53 when the patient voluntarily decides to stop the procedure.

When your gastroenterologist stops a procedure, you can use modifier 52 (Reduced services) to seek payment, but you have to be careful not to confuse it with modifier 53 (Discontinued procedure).

Read on to see examples for both situations and cash in for the work your physician performed.

Get the Difference Between Reduced and Failed

You will use modifier 52 “to indicate the service was provided as described by the CPT® code description but not fully,” says Laureen Jandroep, CPC, CPC-H, CPC-I, CPPM, CMSCS, CHCI, founder and CEO at CodingCertification.org in Oceanville, N.J. “It usually indicates the fee should be reduced.”

This modifier has two functions. The first is to indicate a service that was significantly less than usually required to fit the code descriptor.

Example: Your gastroenterologist has decided to perform an esophagogastroduodenoscopy (EGD) to examine the lining of the esophagus, stomach, and upper duodenum of a patient as part of a GERD evaluation. The GI begins the diagnostic EGD but stops without examining the entire upper gastrointestinal tract because he encounters an obstructing lesion in the middle of the stomach. In this case, you should attach modifier 52 to 43235 (Esophagogastroduodenoscopy, flexible, transoral; diagnostic, including collection of specimen[s] by brushing or washing, when performed [separate procedure]),” says Michael Weinstein, MD, Vice President of Capital Digestive Care.

Other factors which could justify your gastroenterologist’s reduced services include:

• anatomical variances causing the lumen to be smaller than expected
• the physician’s decision not to complete the procedure for reasons other than the patient’s wellbeing being threatened, like a poor prep or retained debris obstructing the view.

Specifically, you should thoroughly explain the encounter to the payer, and be sure to show why the gastroenterologist decided that finishing the procedure was unnecessary.

Use Modifier 52 Even in Failed Procedure

For example: A patient had a full colonoscopy, and during that procedure, your physician removed a polyp in the transverse colon. The pathology result shows cancerous changes in the polyp; the physician decided that the location of the polyp should be tattooed to allow the surgeon to identify the location. The physician then performed a follow-up colonoscopy to tattoo the site to assist the surgeon in identifying the location during a subsequent surgery. The scope could have been advanced but there was no need to. “This service would be billed as 45381 (Colonoscopy, flexible; with directed submucosal injection[s], any substance) with modifier 52,” says Marcella Bucknam, CPC, CCS-P, CPC-H, CCS, CPC-P, CCC, COBC, CPC-I, internal audit manager at PeaceHealth in Vancouver, Wash.

Stopped or Terminated Procedures End at Modifier 53

When you append a procedure code with modifier 53, you are telling the payer that the doctor could not complete the procedure because the patient’s health and well-being are at risk.

Example: Suppose your gastroenterologist performs a procedure on a patient who is scheduled and prepared for a total colonoscopy. During the procedure, the physician discovers that due to unforeseen circumstances, he cannot advance the scope beyond the splenic flexure. How should you report it?

Code it: You should report the colonoscopy code 45378 (Colonoscopy, flexible; diagnostic, including collection of specimen[s] by brushing or washing, when performed [separate procedure]) with modifier 53 (Discontinued procedure) and appropriate documentation consistent with CMS policy.

CMS policy requires you to use modifier 53. That’s because in case you code this encounter as 45378-52, and you had to go back and do a colonoscopy that you coded 45378, you wouldn’t get paid due to frequency edits.

Watch out: “You can’t use this modifier when the patient deliberately elects to cancel the procedure or service,” adds Weinstein. In fact, CMS states that modifier 53 “is not used to report the elective cancellation of a procedure prior to the patient’s anesthesia induction and/or surgical preparation in the operating suite.”

Check Note for Complete Details

No matter what modifier you use for which situation, payers will need to see thorough notes explaining why the service ended.

“In the case of either modifier 52 or 53, the documentation needs to reflect the circumstances that necessitated reducing or discontinuing the procedure,” says Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians in Leawood, Kan. “Additionally, in the case of modifier 52, I believe the documentation should reflect the extent to which the service was reduced (how much of the procedure was done and what was left undone).”