Gastroenterology Coding Alert

Question: I know that when billing a limited colonoscopy to Medicare I should use modifier -53. From the wording, if the doctor decided to stop the procedure due to poor bowel prep and the patient's health was not in danger, then it qualifies for modifier    -53. But should I only use modifier -53 when billing Medicare and use -52 when billing commercial payers, or should I use -53 for everyone?

Utah Subscriber


Answer: You have to decide if the service was "reduced or eliminated at the physician's discretion," which calls for modifier -52 (Reduced services), or a "discontinued procedure," which merits modifier -53 (Discontinued procedure), to be able to choose between the two modifiers.

Due to extenuating circumstances or those that threaten the well-being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued. One distinguishing factor when applying modifier -52 is that you use it when the physician performs as much of the procedure as possible "without disturbing the identification of the basic service."
 
Adding to the confusion is the fact that neither modifier -52 nor -53 defines "certain circumstances," although the description of modifier -53 does specify that you attach it when the physician terminates a procedure because of risk to the patient's well-being. So, it boils down to deciding if the service is partially reduced or eliminated (-52) or a discontinued procedure (-53).
 
Consequently, many expert coders append only modifier -53 because they feel that "discontinued" means "stopped," regardless of whether the patient was already in surgery. Frequently, a physician stops a procedure because the patient is having a problem. In the case above, your physician halted the colonoscopy because of the patient's poor bowel prep.
 
Note that you cannot append modifier -53 when a procedure is discontinued at the patient's request. To sum up, in the situation you described, you should be able to append modifier -53.
 
Experts also advise that to obtain reimbursement when coding with modifier -53, you should provide easy-to-read, clear, concise documentation explaining in specific detail what the procedure accomplished, what percent was completed, the patient's condition, the extenuating circumstances that caused the discontinuation, and the operative report.
 
CMS guidelines require that payers do a manual claim review, so you can't file an electronic claim for incomplete or canceled procedures. Complete documentation should assist with reimbursement.
 
Be aware, however, that you should check with your carrier and payers, because some may refuse to pay for this modifier or have particular requirements for its use.