Gastroenterology Coding Alert

Anesthesia plays a role, too!

When your gastroenterologist ends a procedure early, it automatically tells you to add a modifier to the procedure code. But what modifier? The use of modifiers 52 and 53 for incomplete procedures, in particular, has created unnecessary confusion among gastroenterology practitioners.

Don't fall victim into the same trap by learning from these 2 scenarios.

1. Procedure Spells 'Physician's Discretion'

Sometimes, your gastroenterologist -- when performing a procedure -- decides to partially reduce or eliminate a portion of the code's requirements. In this case, you would use modifier 52 (Reduced services). The physician's discretion can be made prior or during a procedure.

The CPT's descriptor would usually give you a hint -- when services your gastroenterologist carries out are less than those described. Before adding modifier 52 in your claim, however, make sure no other more appropriate CPT code describes the lesser procedure.

Example: Your gastroenterologist started a colonoscopy, but his operational note indicates he wasn't able to inspect all the way to the patient's cecum, the deepest part of the colon. You would use a colonoscopy code (45378-45392, Colonoscopy, flexible, proximal to splenic flexure ...), and add modifier 52 to the CPT to indicate that the gastroenterologist intended to inspect the ascending or transverse colon, but just couldn't complete the procedure.

Alternative: Proctosigmoidoscopy, 45300-45327 (Proctosigmoidoscopy, rigid ...), and sigmoidoscopy, 45330-45345 (Sigmoidoscopy, rigid ...), are lesser procedures that don't intrude as far into the bowel. Don't confuse them with an incomplete colonoscopy.

Remember, "incomplete" is when a physician plans a procedure, but does not carry on with the procedure for a reason. The physician's intent of what is to be viewed or biopsied prior to the procedure plays an important role in how you would report it, notes Anne Schwartz, coordinator of pediatric gastroenterology and nutrition at Goryeb Children's Hospital at Atlantic Health in Morristown, N.J.

2. Look for the 'Extenuating Circumstance' Clue

Turn to modifier 53 (Discontinued procedure) when your gastroenterologist ends a procedure due to a threat to the patient's well being or other extenuating circumstances. A more common example would be when the equipment your gastroenterologist is using fails, and he has to discontinue the procedure before completion. This is known as an "extenuating circumstance," according to CPT.

You use modifier 53 when your physician encounters an unexpected problem -- beyond her or the patient's control -- that calls for ending the procedure. Unlike modifier 52, the physician doesn't elect to discontinue the procedure as much as he is forced to do so because of the circumstances.

Helpful: Look at your gastroenterologist's documentation to see if the patient underwent anesthesia. You can only use modifier 53 after anesthesia administration and/or a surgical prep took place, and the procedure was actually started.

Example: A patient presents with an occluded tube, and the gastroenterologist removes the tube endoscopically, with the intention of replacing it with a new tube. However, the gastroenterologist decides to terminate the procedure before finishing because the patient's blood pressure drops significantly for an extended period of time. You should report 43246 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with directed placement of percutaneous gastrostomy tube) for the procedure, with modifier 53 appended.

In summary, your decision should all boil down to reading your gastroenterologist's operative report of a discontinued service, and simply looking at the reason for the discontinuance. Extenuating circumstance would lead to using modifier 53, while physician's discretion would mean adding modifier 52.

Facility difference: If you are coding only for facility payment, such as for an ambulatory surgical center (ASC), use modifiers 73 (Discontinued outpatient procedure prior to anesthesia administration) or 74 (Discontinued outpatient procedure after anesthesia administration) instead of 52 and 53.