Gastroenterology Coding Alert

Question: The patient didn’t prep properly, and therefore the gastroenterologist couldn’t complete a patient’s colonoscopy. Can I still code the procedure?

Nebraska Subscriber

Answer: Your provider did attempt the colonoscopy, and did start the procedure, so it’s important they be reimbursed for the work they were able to do. However, since they couldn’t follow through to the end of the procedure, the claim needs to reflect that. This is a situation where you’d need to append modifier 53 (Discontinued procedure).

Modifier 53 (Discontinued procedure) is often misunderstood, partly because of its similarity to modifier 52 (Reduced services). Essentially, when you use modifier 53, you’re identifying a situation where the physician terminates the procedure due to extenuating circumstances or those that may threaten the patient’s well-being. This differs from modifier 52, which you should use when the physician completes the procedure but elects to reduce a portion of the service or procedure, though not because the patient’s well-being is in question.

However, in the case of colonoscopies, you can append modifier 53 without the patient well-being factor.

For example, your gastroenterologist performs a screening colonoscopy and was able to advance to the cecum. However, due to poor prep which limits visualization, the provider cannot continue and therefore requires the patient to return in one month to repeat the screening exam.

Using modifier 53 in this scenario stops the clock and allows the patient a full screening benefit when they return for the complete procedure.

Documentation alert: When coding with modifier 53, you should provide easy-to-read, clear, concise documentation explaining in specific detail what the procedure accomplished, what percent your GI completed, the patient’s condition, the extenuating circumstances that caused the discontinuation, and the detailed operative report. Be sure to check with your payers because some may refuse to pay for this modifier or have particular requirements for its use.