Gastroenterology Coding Alert

Be aware of cms /cpt guideline differences to avoid denials.

When your gastroenterologist performs a colonoscopy, but is unable to completely visualize and inspect the entire colon, you'll need to use modifier 52 (Reduced services) or 53 (Discontinued procedure). What makes your job challenging is that different payers have different rules. Use these tips to ensure you append the right modifier every time.

Distinguish Between Lesser and Incomplete Procedures

When your gastroenterologist documents that he performed a colonoscopy, you'll turn to codes 45378-45392 (Colonoscopy,flexible, proximal to splenic flexure...). During these procedures, your physician is performing an inspection of the large intestine, starting at the anus and advancing all the way to the cecum thru the ileocecal valve into the ileum.

Pitfall: If your gastroenterologist states that he didn't insert the scope as far into the bowel as a colonoscopy indicates, you may be tempted to report the procedure as a sigmoidoscopy such as 45330 (Sigmoidoscopy, flexible; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]).

According to the Medicare Claims Processing Manual, "Failure to extend beyond the splenic flexure means that a sigmoidoscopy rather than a colonoscopy has been performed." A sigmoidoscopy is an inspection of the descending colon only.

The catch: Prior to January 1, 1997, when modifier 53 was introduced, the physician and/or facility billed for a sigmoidoscopy. Now you should code the colonoscopy with 53 modifier appended since the intent of the procedure was to view the entire colon, says Kathleen Mueller, RN, CPC, CCS-P, CMSCS, PCS, coding consultant in Lenzburg, Ill.

Define 'complete': Check your physician's documentation to see whether the scope passed the splenic flexure -- the bend that separates the transverse colon from the descending colon."As soon as the scope passes beyond the splenic flexure it is considered a complete colonoscopy and should be billed accordingly," says Catherine Du Toit, CPC, PCS, CGIC, coding consultant in Doylestown, Penn.

"I have seen physicians note that a procedure was aborted when the scope had reached the transverse colon, which is beyond the splenic flexure, but due to whatever reasons, poor prep or contraindications, they aborted the procedure." In this case, modifier 52 (Reduced services) for the professional side would be appropriate as per CPT instruction, she says.

Avoid CMS vs. CPT Pitfalls

If you determine your gastroenterologist planned to perform a colonoscopy, but was unable to do so, you're correct to report an incomplete colonoscopy. CMS and CPT differ on which modifiers to append for an incomplete colonoscopy, however, so be sure you know how each of your payers wants you to report the procedure.

Option 1: For Medicare and payers that follow CMS guidelines, you should append modifier 53 (Discontinued procedure) to 45378 (... diagnostic, with or without collection of specimen[s] by brushing or washing, with or without colon decompression [separate procedure]) for an incomplete colonoscopy.

The Medicare physician fee schedule database has specific values for code 45378-53. These values are the same as for code 45330 (sigmoidoscopy) since failure to extend beyond the splenic flexure means that the physician performed a sigmoidoscopy rather than a colonoscopy. CMS advises using code 45378-53 if your physician intended to perform a complete colonoscopy, however, because "other Medicare physician fee schedule database indicators are different for codes 45378 and 45330" (www.cms.hhs.gov/manuals/downloads/clm104c12.pdf).

Option 2: CPT instructs you to report an incomplete colonoscopy by attaching modifier 52 to the appropriate colonoscopy code (for example, 45378).

Example: A patient came in for a screening colonoscopy. The gastroenterologist was not able to complete the procedure due to semi-formed solid stool. He got to the sigmoid colon but then was forced to abort the procedure. He wants the patient to return for the complete colonoscopy tomorrow. If the patient has Medicare, you'll report 45378-53 for this case. Most payers follow CMS rules but if the patient has an insurance company that follows CPT rules rather than Medicare guidelines, report 45378-52.

Rely on 53 for Screenings

Medicare Screening: When your gastroenterologist is unable to get past the splenic flexure during a screening colonoscopy, you would append modifier 53 no matter which payer you are billing, Mueller says.

When you're reporting a screening colonoscopy for Medicare, you'll need to report G0105 (Colorectal cancer screening; colonoscopy on individual at high risk) or G0121 (Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk) depending on the patient's history. Medicare covers a screening colonoscopy for high risk patients as often as every 24 months if indicated. You'll use G0105 for these screening procedures. Medicare covers a screening colonoscopy for patients who are not high risk once every ten years. You'll report G0121 for those patients.

Bottom line: If your gastroenterologist performs a screening colonoscopy but is unable to completely visualize the entire colon, then you'll need modifier 53. "When scoping a Medicare patient for screening G0105 or G0121, modifier 53 is applied no matter how far the scope goes since these are time-driven codes," Mueller says.

Tip: Modifier 53 indicates to the payer that the procedure was not completed and stops the time clock on frequency-based codes. This allows the physician and facility to receive a reduced reimbursement for the discontinued procedure and full reimbursement when the procedure is completed. If not billed correctly, there would be no reimbursement for the completed procedure.