Gastroenterology Coding Alert

Opt for -53 if procedure is stopped for safety If your gastroenterologist has to put the brakes on an EGD before she finishes, experts recommend attaching either modifier -52 (Reduced services) or modifier -53 (Discontinued procedure) to the EGD code.
 
EGD Service Can Be Stopped by Obstruction Let's say the gastroenterologist is performing a diagnostic EGD. While inserting the endoscope, he encounters an obstruction.

After several attempts to circumvent the obstruction, the gastroenterologist decides that it is not in the patient's best interests to continue the procedure. According to CPT 2005's descriptor for modifier -53, this would qualify as a discontinued procedure. On the claim, you should:
   report 43235 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]) for the EGD.
   attach modifier -53 to 43235 to show that the EGD was a discontinued procedure. Rationale: Coders can use modifier -53 when a gastroenterologist stops a procedure "due to extenuating circumstances or those that threaten the well-being of the patient," according to CPT 2005. On the claim, try to include as much documentation as possible about the discontinued EGD.
 
Other modifier -53 opportunities: Here are some other situations in which your gastroenterologist may also have to stop an EGD, says Margaret Lamb, RHIT, CPC, of Great Falls Clinic in Great Falls, Mont.:
  Patient begins thrashing or has a seizure during the EGD.
   Patient begins bleeding severely during the EGD.
   Patient becomes unstable due to a condition such as atrial fibrillation, bradycardia, or breathing trouble. You must explain the encounter to the payer as accurately as possible and the exact reasons that the gastroenterologist felt it was necessary to stop the EGD. Use -52 Sparingly ... Very Sparingly While you won't likely use modifier -53 often, you'll probably use modifier -52 even less. Coders should use modifier -52 when "a service or procedure is partially reduced at the physician's discretion," this year's CPT manual states.
 
Explanation: If, for some reason, the gastroenterologist begins the diagnostic EGD "but does not feel the need to scope the entire upper gastrointestinal tract because the procedure can be accomplished without performing the entire procedure," then you could use modifier -52, Lamb says.
 
If your gastroenterologist begins a diagnostic EGD and decides that he does not need to continue for reasons other than the patient's well-being, you should:
  report 43235 for the EGD.
  attach modifier -52 to 43235 to show that the gastroenterologist discontinued the procedure. Documentation Requirements Similar for Modifiers Successful modifier -52 claims must include detailed documentation similar to the sort you would submit for a modifier -53 claim.

When reporting the above example, thoroughly explain the encounter to the payer, and be sure to show why [...]