General Surgery Coding Alert

Question: My surgeon was performing a diagnostic EGD. While inserting the endoscope, he encountered an obstruction. After several attempts to get around the obstruction, the surgeon decided it was in the patients best interest to end the procedure. Can I still report the procedure?

Washington Subscriber

Answer: You can, and should, still report a procedure that your surgeon has to discontinue for the patients safety and health.

In this case, youll need to use modifier 53 (Discontinued procedure) and append it to the diagnostic EGD code. So youll report 43235-53 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]).

Rationale: You can use modifier 53 when your surgeon stops a procedure due to extenuating circumstances or those that threaten the well-being of the patient, according to CPT. Modifier 53 describes an unexpected problem, beyond the physicians or patients control, that necessitates ending the procedure. The physician doesnt elect to discontinue the procedure so much as he is forced to do so because of circumstances.

In addition to circumstances that put the patients health at risk, you might also choose modifier 53 if your surgeon must stop the procedure due to equipment failure or because he cannot go on (for example, if the physician cuts himself and cannot continue).

Pitfall: Dont confuse modifiers 53 and 52 (Reduced services). To apply modifier 52, the reduction of services must have occurred by choice (either the physicians or the patients) rather than necessity. If your physician determines that the patient requires a service but at a lesser level than the complete code description indicates, or if patient elects to cancel the procedure prior to its completion, then modifier 52 is appropriate. You can also report modifier 52 when your surgeons documentation shows that he did not complete all the work a code represents.

Example: If, for some reason, your surgeon began the diagnostic EGD but decided not to scope the entire upper gastrointestinal tract, then you could use modifier 52.

--  Technical and coding advice for You Be the Coder and Reader Questions provided by Marcella Bucknam, CPC, CCS-P, CPC-H, CCS, CPC-P, CPCOBGYN, CPC-CARDIO, manager of compliance education for the University of Washington Physicians (UWP) and Childrens University Medical Group (CUMG) Compliance Program.