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 [...]