Gastroenterology Coding Alert

When an endoscopic procedure is discontinued, gastroenterologists should be able to receive reimbursement for the work that was completed. Although Medicare publishes reporting guidelines for incomplete colonoscopies, it is unclear whether modifier -52 (reduced services) or -53 (discontinued procedure) should be used to report other incomplete endoscopic procedures. In some circumstances, the gastroenterologist may substitute a lesser-valued, unmodified procedure code in place of the discontinued procedures code or bill for an evaluation and management (E/M) service. In addition, the Health Care Financing Administration (HCFA) recently designated two new modifiers for use by ambulatory surgical centers (ASCs) when billing discontinued procedures.

The discontinued procedure that most often occurs in gastroenterology is the incomplete colonoscopy, which is defined by CPT and Medicare as a failure to advance the endoscope beyond the splenic flexure. Common causes for an incomplete colonoscopy include a stricture, obstructing lesion, unusual anatomy or inadequate bowel preparation.

Medicare Requires Modifier -53

CPT and Medicare do not agree on the appropriate modifier to report an incomplete colonoscopy. CPT states, (F)or an incomplete colonoscopy with full preparation for a colonoscopy, use a colonoscopy code with modifier -52 and provide documentation.

On the other hand, the Medicare Carriers Manual (MCM) states that an incomplete colonoscopy is billed and paid using colonoscopy code 45378 with modifier -53. Medicare has established a relative value unit (RVU) for 45378-53 in its physician fee schedule database that is the same as for a flexible sigmoidoscopy (45330) performed in an office setting. The operative report and a letter explaining the circumstances that required the discontinuation of the procedure should be included with the claim for the incomplete colonoscopy. In addition to the CPT code, gastroenterologists may want to report V64.3 (procedure not carried out for other reasons) on the claim.

Dont Code for Flexible Sigmoidoscopy Instead

Although many gastroenterologists will report a flexible sigmoidoscopy instead of incomplete colonoscopy to avoid having to file the extra paperwork required with the use of modifier -53 (or -52), reimbursement to the gastroenterologist working in an ASC is higher with 45378-53. One of the reasons Medicare created the 45378-53 designation is so that gastroenterologists in an ASC setting would not be penalized with a site-of-service differential for reporting flexible sigmoidoscopies, which is not an approved ASC procedure, according to Michael Weinstein, MD, a gastroenterologist in Washington, D.C., and a member of the American Medical Association (AMA) CPT advisory committee. This penalty is reflected in the Medicare Physicians Fee Database, which lists a 1.89 facility RVU for 45378-53 and a 1.49 facility RVU for 45330.

Medicare has not specified, however, which modifier should be used to report other incomplete endoscopic procedures, and many gastroenterologists and coding professionals disagree about what to report. Weinstein recommends using modifier -53 when reporting incomplete colonoscopies because that is what Medicare specifies, and using modifier
-52 for all other incomplete endoscopic procedures.

In contrast, Terry A. Fletcher, CPC, CCS-P, a healthcare coding consultant in Laguna Beach, Calif., primarily uses modifier -53 and reserves modifier -52 for instances when there is not a specific CPT code to describe the procedure that was performed. She adds, Modifier -52 should be used only when a portion of the procedure defined by CPT has been done.

Reporting an Incomplete EGD, ERCP

Although the incomplete colonoscopy is the only discontinued procedure for which Medicare has established an RVU, there are two other endoscopic procedures that gastroenterologists may have to discontinue due to an inability to advance the endoscope an esophagogastroduodenoscopy (EGD) and an endoscopic retrograde cholangiopancreatography (ERCP). For an EGD (43235), the gastroenterologist has to get the endoscope into the stomach, says Weinstein. If theres an esophageal stricture, then the scope may not be able to pass through to the stomach, and the gastroenterologist will only be able to complete an esophagoscopy.

In the case of an incomplete EGD, Weinstein says gastroenterologists may report the procedure from the esophagoscopy family of codes (43200-43228) that most closely describes the service that was performed. As an alternative, the gastroenterologist also may select a procedure from the EGD family of codes (43235-43259) and attach a modifier.

A gastroenterologist also may have to discontinue an ERCP. During an ERCP, the gastroenterologist needs to be able to visualize either the bile or pancreatic ducts, says Weinstein. If these ducts cannot be accessed, the gastroenterologist eventually will have to discontinue the procedure. However, the endoscope will have been advanced into the stomach, and the gastroenterologist will have performed the equivalent of an EGD.

Although the advancement of the endoscope would indicate that an EGD code should be used to report the service, Weinstein suggests that gastroenterologists use the ERCP code 43260 and attach modifier -52 or -53 for better reimbursement. You are probably hurting yourself by billing for an EGD in this situation because many times a gastroenterologist may spend close to an hour attempting to visualize the bile or pancreatic ducts. This is more time than is usually spent performing an EGD.

Using a modifier requires that a letter explaining why the procedure was discontinued and an operative report be included in the claim. This gives the gastroenterologist an opportunity to document the amount of time that he or she spent attempting the ERCP.

Report E/M Encounter if Scope Is Not Inserted

Gastroenterologists also may discontinue an endoscopic procedure before the scope is inserted in the patient. The gastroenterologist may begin to administer conscious sedation and find that the patient is not tolerating the sedative or the scope insertion well, says Weinstein. Or the gastroenterologist wont even begin conscious sedation because the patient has an illness or is on medication that is contraindicated for the procedure.

In these situations when the procedure is terminated before it has begun, the most the gastroenterologist can report is an E/M service, according to Weinstein. If the gastroenterologist documents the patients history and examination and makes the decision not to sedate or decides that the patient isnt tolerating the sedation well, then he or she should be able to bill some level of E/M service based on the level of history, examination and medical decision-making that occurred, he explains.

Modifiers for Facilities

Gastroenterologists who own an ASC also should be aware that facilities can report discontinued procedures with the use of two modifiers recently designated by Medicare. Modifier -73 (discontinued outpatient procedure prior to anesthesia administration) should be attached to the procedure code submitted by the ASC when the procedure has been terminated after a patient has been prepped for surgery but before the introduction of anesthesia. According to a program memorandum issued by HCFA (transmittal no. A-99-41, September 1999) payment for services with modifier -73 attached will be 50 percent of the facility rate, subject to ASC payment calculation.

When the procedure is terminated after the induction of anesthesia or after the scope has been inserted, modifier -74 (discontinued outpatient procedure after anesthesia administration) should be attached to the procedure code submitted by the ASC. There will be no reduction in payment for services reported with modifier -74.