Gastroenterology Coding Alert

Question: Is it correct to use modifier 74 to describe a colonoscopy in which the physician could only go up to the sigmoid colon due to advanced disease?

Texas Subscriber

Answer: Possibly, but you need to take several factors into account.

First, you should only use modifier 74 (Discontinued outpatient procedure after anesthesia administration) for ambulatory surgery center (ASC) facility charges.

You should consider this an "incomplete" colonoscopy. An incomplete colonoscopy relies on whether the physician did or did not pass the splenic flexure. Because your gastroenterologist ended at the sigmoid colon, he did not pass the splenic flexure.

Look to your payer: If your patient is on Medicare, you've got good insight into which modifier you should use. According to Medicare, if your gastroenterologist performs an incomplete colonoscopy, meaning she doesn't reach the splenic flexure, you'll use modifier 53 (Discontinued procedure). However, CPT recommends that when the colonoscopy does not extend past the splenic flexure that you should use modifier 52 (Reduced services). Private payers may take their cue from either CPT or Medicare's payment policies.

Look to your location: In an ASC, report the appropriate procedure code for the case and append modifier 73 (Discontinued outpatient procedure prior to anesthesia administration) or modifier 74, depending on when the physician canceled the case.