Gastroenterology Coding Alert

Question: A patient came in for a colonoscopy, but all we did was set the IV before she changed her mind and left. I know we cannot use modifier 53 (Discontinued procedure) because the patient had not started anesthesia. We are in an ambulatory surgery center (ASC), and our carrier has inferred that we cannot bill the IV either. What should I do?

Kentucky Subscriber

Answer: Your ASC should report 45378 (Colon-oscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen[s] by brushing or washing, with or without colon decompression [separate procedure]) with modifier 73 (Discontinued outpatient procedure prior to anesthesia administration).

Your physician cannot code a procedure. She can, however, report an E/M service (99201-99215, Office or other outpatient visit for the E/M of a patient ...) if the physician saw the patient before she left the center and documented the patient interaction.