Gastroenterology Coding Alert

Question: Our gastroenterologist began performing an upper GI on an inpatient in the hospital (43191, Esophagoscopy, rigid, transoral; diagnostic, including collection of specimen[s] by brushing or washing when performed [separate procedure]). However, the gastroenterologist had to discontinue the surgery because the patient's health became endangered. What is the correct modifier to append in this situation?

Codify Subscriber

Answer: The modifier you are thinking of is modifier 53 (Discontinued procedure), which you would append when the physician begins a procedure or diagnostic test and then decides to terminate it because continuing the procedure threatens the patient's health. So, you would append modifier 53 to the CPT® code of the procedure that was discontinued - which in this case is 43191.

Remember, you should never append modifier 53 in these instances:

• When you're only reporting an evaluation and management (E/M) code
• When a procedure is cancelled for elective reasons before the patient's anesthesia induction and/or surgical preparation in the operating suite
• In an outpatient hospital or Ambulatory Surgical Center (ASC). Note: Instead, in an outpatient hospital or ASC, to report a previously scheduled procedure or service that is partially reduced or canceled as a result of extenuating circumstances or those that threaten the wellbeing of the patient prior to or after administration of anesthesia, look to modifier 73 (Discontinued out-patient hospital/ambulatory surgery center (ASC) procedure prior to the administration of anesthesia) or modifier 74 (Discontinued out-patient hospital/ambulatory surgery center (ASC) procedure after administration of anesthesia).

Always submit documentation: Submitting modifier 53 alone does not provide the payer with enough information to know how to correctly reimburse the provider. So, make sure you submit the supporting documentation for appending modifier 53. The documentation must state that the physician actually started the procedure, why it was medically necessary for him to discontinue the procedure, and what percentage of the procedure he did perform.

Caution: Make sure you understand the difference between modifier 53 and modifier 52 (Reduced services).

Modifier 53: "Due to extenuating circumstances or those that threaten the wellbeing of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued," according to Appendix A in the CPT^® manual. "This circumstance may be reported by adding modifier 53 to the code reported by the individual for the discontinued procedure."

Modifier 52: On the other hand, modifier 52 normally applies when the physician plans or expects a reduction in services as represented by the CPT^® code. This reduction of services must occur by choice (by either the physician or patient) rather than necessity (which falls under modifier 53). Reporting modifier 52 tells the payer that the physician completed the procedure, but not the full procedure as indicated by the code descriptor.