Gastroenterology Coding Alert

Question: Our physician did a colonoscopy on a patient back in August 2013 during which he performed a snare removal of a polyp. He also biopsied another polyp but did not remove it.  The patient returned in Feb 2014 to have another colonoscopy for “removal of polyp which was biopsied previously.” Patient has Tufts. Would I be correct in using modifier 76 on this?

Minnesota Subscriber

Answer: You need not use any modifier when reporting the removal of the polyp in the second visit (Feb 2014). A modifier is not necessary as the global period for colonoscopy performed initially (Aug 2013) has lapsed. Since the second procedure is not within the global period of the first procedure, you will not need a modifier such as 76 (Repeat procedure or service by same physician or other qualified health care professional).

Also, you need to remember that the two procedures in this case scenario are not related to the same polyp. So, you will report the appropriate polypectomy code for the first visit and then report a separate polypectomy code for the second visit without using any modifiers for both the visits.

However, if in the initial visit, your clinician was unable to remove the polyp completely and then attempted to remove the same in the second visit, you will then have to use a modifier for both the visits. Here, you can consider reporting the appropriate polypectomy code with the modifier 53 (Discontinued procedure) or 52 (Reduced services) as is appropriate, for the initial visit. You report the polypectomy code with the modifier 52 for the second visit.

Caveat: If the place of service is an ambulatory service center, you should consider using other modifiers if the procedure was discontinued. You should append modifier 73 (Discontinued outpatient procedure prior to anesthesia administration) or modifier 74 (Discontinued outpatient procedure after anesthesia administration), depending on when the physician canceled the case.