Gastroenterology Coding Alert

Question: The gastroenterologist performed a diagnostic upper gastrointestinal endoscopy (EGD). While inserting the endoscope, he encountered an obstruction and was unable to progress beyond the esophagus. After several failed attempts at insertion, he decided that stopping the procedure was in the patient's best interest. Does this count as a reduced procedure and can I use modifier 52?

Maine Subscriber

Answer: You should not use modifier 52 (Reduced services) for this procedure. Instead, report the appropriate esophagoscopy code (43200-43232) and append modifier 53 (Discontinued procedure). You'll use 53 instead of 52 because the physician stopped the procedure out of concern for the patient's well being.

You're unlikely to use 52 with an endoscopy. If the physician begins a diagnostic EGD and decides not to scope the entire tract for reasons unrelated to the patient's health (such as an equipment problem after the scope entered the stomach and before it reached the duodenum), however, you should append the reduced-services modifier.

Pointer: You may want to consider adding modifier 22 (Increased procedural services) since your gastroenterologist had to try inserting the scope multiple times. If that extended the work to the point that extra reimbursement would be appropriate, attach modifier 22 on your claim.