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Diagnostic Endoscopy Reporting Depends on Circumstances

Most experienced coders are familiar with the rule, “surgical endoscopy always includes diagnostic endoscopy.” These guidelines are outlined in Chapter I of the “General Correct Coding Policies for National Correct Coding Initiative Policy Manual for Medicare Services,” which states:

Diagnostic endoscopy is never separately reportable with another endoscopic procedure of the same organ(s) when performed at the same patient encounter. Similarly, diagnostic laparoscopy is never separately reportable with a surgical laparoscopic procedure of the same body cavity when performed at the same patient encounter.

If a diagnostic endoscopy is the only procedure performed, you always may report it. But, you may also report a diagnostic endoscopy separately if the diagnostic endoscopy leads to an open surgical procedure. Chapter 1 of the NCCI Policy Manual (above) further explains:

If a diagnostic endoscopic procedure results in the decision to perform an open procedure, both procedures may be reported with modifier 58 appended to the HCPCS/CPT code for the open procedure. However, if the endoscopic procedure preceding an open procedure is a “scout” procedure to assess anatomic landmarks and/or extent of disease, it is not separately reportable.

By appending modifier 58 Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period to the open procedure code, you alert the payer that the open procedure was both a result of, and more extensive than, the diagnostic endoscopy. Note that you may report the diagnostic endoscopy separately only if it truly results in the decision to perform the open procedure. As instructed, above, you may not separately report a diagnostic endoscopy that serves only to examine the surgical field prior to a planned open procedure.

John Verhovshek
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About Has 577 Posts

John Verhovshek, MA, CPC, is a contributing editor at AAPC. He has been covering medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University.

2 Responses to “Diagnostic Endoscopy Reporting Depends on Circumstances”

  1. Adriana Salomon says:

    Is there no reduced modifier (52) to be placed on the endoscopic procedure? This was very helpful information, because I have not been coding the endoscopic procedure. Thank you.

  2. Kathy Heimerman says:

    If a diagnostic laparoscopy (not endoscopy) is performed and the decision to perform an open laparotomy is made based on the diagnostic laparoscopy, is the diagnostic laparoscopy billable? It follows the same logic, but stopped short of actually saying that. Anyone know?