Gastroenterology Coding Alert

Question: Our gastroenterologist was performing a diagnostic EGD. While inserting the endoscope, he encountered an obstruction. After several attempts to get around the obstruction, the physician decided it was in the patient’s best interest to end the procedure. Can I still report the procedure?

Washington Subscriber

Answer: You can, and should, still report a procedure that your gastroenterologist has to discontinue for the patient’s safety and health.

In this case, you’ll need to use modifier 53 (Discontinued procedure) and append it to the diagnostic EGD code. So you’ll report 43235-53 ( Esophagogastroduodenoscopy, flexible, transoral; diagnostic, including collection of specimen[s] by brushing or washing, when performed [separate procedure]).

Why: You can use modifier 53 when your gastroenterologist stops a procedure due to extenuating circumstances or those that threaten the well-being of the patient, according to CPT^®. Modifier 53 describes an unexpected problem, beyond the physicians or patients control that necessitates ending the procedure. The physician doesn’t elect to discontinue the procedure so much as he is forced to do so because of circumstances.

In addition to circumstances that put the patient’s health at risk, you might also choose modifier 53 if your physician must stop the procedure due to equipment failure or because he cannot go on (for example, if the physician cuts himself and cannot continue).

Pitfall: Don’t confuse modifiers 53 and 52 (Reduced services). To apply modifier 52, the reduction of services must have occurred by choice (either the physicians or the patients) rather than necessity. If your physician determines that the patient requires a service but at a lesser level than the complete code description indicates, or if patient elects to cancel the procedure prior to its completion, then modifier 52 is appropriate. You can also report modifier 52 when your physician’s documentation shows that he did not complete all the work a code represents.

Example: If, for some reason, your GI began the diagnostic EGD but decided not to scope the entire upper gastrointestinal tract, then you could use modifier 52.