Outpatient Facility Coding Alert

Reader Question:

Know When to Append 52 vs. 53

Published on Thu Jun 16, 2016

Question: Our gastroenterologist performed a diagnostic colonoscopy but was unable to get past the rectum due to a tight surgical colorectal anastomosis. Our gastroenterologist suggested that the patient would need surgery to correct the anastomosis. He also mentioned inadequate preparation for the procedure and discontinued the procedure. He then sent the patient to radiology for a barium enema examination. Can I bill the colonoscopy procedure that our gastroenterologist attempted? If so, should I use modifier 52 or 53?

Oklahoma Subscriber

Answer: Because the physician started out with the procedure with the intention of performing a complete colon exam, you can bill the colonoscopy with 45378 (Colonoscopy, flexible; diagnostic, including collection of specimen[s] by brushing or washing, when performed [separate procedure]). However, for professional services billing, since the procedure was discontinued due to an unexpected situation (colorectal anastomosis), you will have to append modifier 53 (Discontinued procedure) to the colonoscopy code.

The modifier 53 is added when the procedure is discontinued in lieu of some circumstance that is encountered wherein the well being of the patient might be questionable if the procedure is continued further. It is also appended where your gastroenterologist had to discontinue the procedure due to an unexpected situation.

In this scenario, you cannot use modifier 52 (Reduced services) with the colonoscopy code. You would use the modifier 52 if your gastroenterologist stopped the procedure out of choice or if the patient elected to stop the procedure from completion. As your gastroenterologist encountered a situation wherein he could not continue the procedure and complete it, you cannot use the modifier 52 in this situation.

Note: If billing for the technical component, select from one of the following modifiers depending upon whether or not anesthesia had been started in conjunction with the procedure:

73 (Discontinued Outpatient Hospital/Ambulatory Surgery Center (ASC) procedure prior to the administration of Anesthesia)
74 (Discontinued Outpatient Hospital/Ambulatory Surgery Center (ASC) procedure after administration of Anesthesia).