Gastroenterology Coding Alert

Question: I-ve heard conflicting guidelines on whether to append modifier 52 or modifier 53 to report an incomplete colonoscopy. Which is correct?


Nevada Subscriber


Answer: The correct answer depends on your payer.

For Medicare and other payers that follow Medicare guidelines, you should append modifier 53 (Discontinued procedure) to 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]) for an incomplete colonoscopy.

You can find these instructions in section 15100B of the Medicare Carriers Manual. Medicare also includes a separate fee schedule line item for 45378-53, consistent with the MCM guidelines, which states:

An incomplete colonoscopy (e.g., the inability to extend beyond the splenic flexure) is billed and paid using colonoscopy code 45378 with modifier 53. The Medicare physician fee schedule database has specific values for code 45378-53. These values are the same as for code 45330, sigmoidoscopy, as failure to extend beyond the splenic flexure means that a sigmoidoscopy rather than a colonoscopy has been performed. But, code 45378-53 should be used when an incomplete colonoscopy has been done because other Medicare physician fee schedule database indicators are different for codes 45378 and 45330.
 
The above guidelines assume that the physician intended to perform a colonoscopy rather than a sigmoidoscopy. If the physician intended to perform a sigmoidoscopy, you would report 45330 (Sigmoidoscopy, flexible; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]) rather than 45378-53.

In direct contradiction to CMS guidelines, CPT instructs you, -For an incomplete colonoscopy [in other words, the scope does not progress beyond the splenic flexure], with full preparation for a colonoscopy, use a colonoscopy code with the modifier 52 [Reduced services] and provide documentation.-

Therefore, for non-Medicare payers that follow AMA/CPT guidelines, you should report an incomplete colonoscopy using 45378-52, for example.

Tip: If you-re unsure whether your payer follows CMS or CPT guidelines in this case, be sure to ask.