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CBaez

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Our doctor did a biopsy of a rectosig. pylop but did not make it past the sigmoid colon and when I billed a bx with a modifer 53, Medicare denied the charge. Has anyone else had the same issue where the doctor did not go past the splenic flexure and biopised?

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you use the modifier for a cancelled procedure and then tried to bill for something accomlished. you need to you the 52 for reduced procedure which a procedure partially completed.
 
read the description for modifer 53 it is used for cancellation of a procedure that threaten the patients life.
 
You coded correctly, modifier 52 is incorrect. Per CPT, Medicare, and most commercial payers "if the physician is unable to advance the scope beyond the splenic flexure, due to unforeseen circumstances, report the scope code with modifier 53 and appropriate documentation." -CPT Coding Guideline, Endoscopy. What was your denial reason?
 
The 52 is correct in that it is used for an incomplete procedure when part is completed. There are two schools of thought on this and both are somewhat correct. You can code for the procedure completed with no modifier or you can code for the procedure attempted with the 52. You are correct that a colonoscopy is not unless it passes the splenic flexure and should be billed as a sigmoidoscopy. However in more recent years the philosophy has changed on that especially when a procedure such as a biopsy is performed.
The problem here is by using the 53 modifier you have communicated that the procedure was discontinued as in not performed, when you then also bill for a biopsy, which according to your modifier is not possible. Therefore the choices are to code it as a sigmoid with a biopsy or a colonoscopy reduced with a biopsy.
 
You are not communicating that you did not perform the procedure with a 53. you are telling them that for the health and best interest of the patient OR extenuating circumstances, after anesthesia was induced the Dr. decided they could not continue. I have used modifier 53 in instances where a polyp was removed and/or biopsied with Medicare and have sucessfully been paid. Medicare does not want you to bill a sigmoid if your intenet going in was a colonoscopy, they are very clear on this. The following link is very helpful and while the exact situation as stated above is not in this text it is helpful. http://www.gastro.org/practice/coding/coding-faqs-screening-colonoscopy
Please also see this MLN Matters
http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R52CP.pdf
also helpful.
 
neither of these articles address this situation. I agree if the coloscopy is attempted and cannot be completed then use the 53 modifier, and as I indicated there have always been 2 schools of thought on this. However in this scenario you have a diagnostic procedure completed during the attempt for a colonoscopy. So the choice is to bill for the procedure that was done or bill for the attempted procedure reduced. it is not a discontinued procedure any longer.
 
tcade

If the procedure started out as a colonoscopy, thats what needs to be billed, also if physician did not get past the splenic flexure then you would bill with a 53 modifier for Medeicare all other insurances would be a 52 modifier. So if the physician did biopsies or removed a polyp by biopsy the code would be 45380/53 for medicare patients. Reimbursement is higher on a 45380/53 than a sigmoidoscopy and that was not the physicians intention to begin with. You cannot bill a complete colonoscopy becuase that was not performed on the patient. Good Luck
 
You bill the colon with modifier 53 and it will usually be reimbursed as a flex sig. That is why you do not code an incomplete colon as a flex sig.
 
we bill a modifier 74 for limited procedure. When they are not able to advance to 70 cm or the splenic flexure and have had no denials. I believe 74 takes place of the 53.
 
I believe the 74 modifier is for the facility billing only. The 53 is used for professional/physician billing.
 
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