Gastroenterology Coding Alert

Question: How should I charge for a colonoscopy when the patient wants to discontinue the procedure after five minutes? Should we still charge the patient?

Indiana Subscriber

Answer: In certain circumstances, gastroenterologists may find it necessary to alter or discontinue a procedure at the physician's discretion or because of unanticipated risk to the patient. When this occurs, modifiers can be used to inform the payer that a defined service was attempted, but altered by specific circumstances.

Two modifiers are commonly used in these situations. Modifier -52 (Reduced services) indicates that a service was reduced or eliminated at the gastroenterologist's discretion, according to CPT 2002, Appendix A. Modifier -53 (Discontinued procedure) identifies a procedure that was terminated due to circumstances that create risk for the patient.

In your scenario, the patient elected to terminate the procedure, rather than medical necessity requiring the procedure's termination. Therefore, you should report the colonoscopy (e.g., 45378, Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen[s] by brushing or washing, with or without colon decompression [separate procedure]) appended with modifier -52.

CPT's introduction to the endoscopy section states, "For an incomplete colonoscopy, with full preparation for a colonoscopy, use a colonoscopy code with the modifier -52 and provide documentation." So, regardless of whether the patient wants to discontinue the procedure five minutes or 30 minutes into the procedure, modifier -52 appropriately describes an elected termination.

Of course, you should document when and why the service was reduced or discontinued. Explain the exact circumstances that led to the decision to reduce or terminate the procedure. Send a cover letter with the claim and the operative note so the payer can make an informed decision on how to adequately price the level and extent of service you provided. Bill the colonoscopy at full fee, send in the claim with documentation, and let the payer choose the fee.

Coding information for You Be the Coder and Reader Questions provided by Jennifer Bahm, CPC, for George Chin, MD, in Aurora, Colo; Erica Folker, CPC, medical coding specialist, Mercy Health System, Janesville, Wis.; and Staci Jordan CPC, CCS-P, reimbursement analyst for the University of Oklahoma Health Sciences Center in Oklahoma City.