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?

California Subscriber

Answer: The answer depends on whether the service was "reduced or eliminated at the physician's discretion," which calls for modifier 52 (Reduced services), or a "discontinued procedure," which calls for modifier 53 (Discontinued procedure).
Use modifier 53 when a gastroenterologist starts a surgical or diagnostic procedure but discontinues it due to extenuating circumstances or those that threaten the patient's well-being.

Helpful hint: One distinguishing factor when applying modifier 52 is that you should use it when the physician performs as much of the procedure as possible "without disturbing the identification of the basic service."

- Did you know? Neither modifier 52 nor 53 defines "certain circumstances," although the description of modifier 53 does specify that you should attach it when the physician terminates a procedure because of risk to the patient's well-being.
- Consequently, many expert coders append modifier 53 only when 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: 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.

- Good advice: 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. 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.