Gastroenterology Coding Alert

Question: Our gastroenterologist recently attempted a colonoscopy through the stoma after removal of the ostomy bag. The procedure notes read like this:

After removing ostomy bag, I attempted to insert my pinky finger into the ostomy site and immediately, there was some bright red blood. I attempted to use the endoscope to advance into the ostomy and met with resistance. Multiple attempts were made with the scope to advance slightly, but due to resistance, I could not advance the scope to any meaningful degree. Given the active bleeding from this site after just finger insertion and attempt at endoscope insertion, I injected 2mL of epinephrine. His heart rate increased appropriately and as expected, however, he did start complaining of back pain. Due to my inability to advance the scope due to narrowing and also the patient's complain of back pain, the procedure was stopped.

How do I report this procedure and should I add modifier 52 or modifier 53 to the code?

Florida Subscriber

Answer: Since the intention of the procedure was a colonoscopy through the stoma, you can choose to use 44388 (Colonoscopy through stoma; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]) for the procedure that your gastroenterologist attempted. However as your gastroenterologist had to discontinue the procedure due to the bleeding, back pain, increased heart rate and the inability to advance the endoscope, you have to append the modifier 53 (Discontinued procedure) to the procedure code.

You cannot use the modifier 52 (Reduced services) to the procedure code as this is more appropriate for use when the procedure is partially done and then your gastroenterologist planned to stop the procedure. When extenuating circumstances forced your gastroenterologist to stop the procedure, you need to go with the modifier 53.