Modifiers and Incomplete Colonoscopy

Modifiers and Incomplete Colonoscopy

For Medicare beneficiaries in the office setting, if a provider preps a patient for a screening colonoscopy but cannot advance the scope past the splenic flexure due to obstruction, patient discomfort, or other complications, append modifier 53 Discontinued services to the appropriate code, per CMS Program Memorandum Transmittal AB-03-114, Change Request 2822. The Transmittal stresses, “Medicare would expect the provider to maintain adequate information in the patient’s medical record in case it is needed by the contractor to document the incomplete procedure.”

The CPT® codebook, in contrast to CMS rules, instructs, “For an incomplete colonoscopy, with full preparation for a colonoscopy, use a colonoscopy code with the modifier 52 [Reduced services] and provide documentation.” Some non-Medicare payers may follow CMS guidelines, while others may adhere to CPT® instructions. Check with individual third-party payers for their recommendations

John Verhovshek

John Verhovshek

John Verhovshek, MA, CPC, is Managing Editor at AAPC. He has covered 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, and a member of the Asheville-Hendersonville AAPC Local Chapter.
John Verhovshek

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About Has 480 Posts

John Verhovshek, MA, CPC, is Managing Editor at AAPC. He has covered 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, and a member of the Asheville-Hendersonville AAPC Local Chapter.

5 Responses to “Modifiers and Incomplete Colonoscopy”

  1. Aashima says:

    Need help with Modifiers for Multiple surgeries.

  2. Karen says:

    CPT states that for an incomplete screening colonoscopy modifier 53 is used. The 52 modifier is used (per CPT) when a therapeutic colonoscopy is performed and does not reach the cecum or colon-small intestine anastomosis.

  3. Sofia Campbell says:

    2017 CPT states (page 300, CPT 2017 Professional, published by AMA):
    “When performing a diagnostic or screening endoscopic procedure on a patient who is scheduled and prepared for a total colonoscopy, if the physician is unable to advance the colonoscope to the cecum or colon-small intestine anastomosis due to unforeseen circumstances, report 45378 (colonoscopy) or 44388 (colonoscopy through stoma) with modifier 53 and provide appropriate documentation.”
    As for modifier 52, it is for an incomplete therapeutic colonoscopy (please see the same page of CPT 2017).
    Therefore, it appears to be that the difference between CMS and CPT is not the modifier, but the anatomic location that needs to be reached in order to be able to report a colonoscopy procedure without the modifier. According to CPT, even if the scope passes the splenic flexure, but doesn’t reach cecum or colon-small intestine anastomosis, a diagnostic or screening colonoscopy procedure still needs to be reported with modifier 53.

  4. Tammy says:

    CPT guidelines state that if the scope doesn’t pass the splenic flexure to bill a sigmoidoscopy. Why a need for -53 or -52 modifier?

  5. James says:

    Thank you for sharing this informative post. Got lot of ideas here. Read more about colonoscopy procedure http://colorectal-surgeon.com.au/colonoscopy/

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