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Wiki Colonoscopy

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dgarrett10

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Eastman, GA
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If a provider does a colonoscopy removes 3 polyps and sends one off for a biopsy. He stated in his op-note that this was poor prep and wants to do another colonoscopy within 2 months. Medicaid denied second colonoscopy request, he now wants me to add a modifier 52 and send in as a corrected claim. I am having a hard time with this because he was able to remove 3 polyps. Please Help!!!
 
Modifier 53

The first question I would ask is whether your physician made it past the splenic flexure. If you read the rules at the beginning of the Endoscopy section you will find the paragraph "report flexible sigmoidoscopy for endoscopic examination during which the endoscope is not advanced beyond the splenic flexure." This is further reiterated by the diagram/flow chart on next page. Since your physician did a successful polypectomy your service is diagnostic. Based on how far he got, you are looking at either a successful completion of a sigmoidoscopy with appropriate type of polyp removal (hot biopsy forceps or snare? 45315) or an incomplete colonoscopy with polyp removal which would be billed with the 53 modifier and have documentation sent in. This leaves the "door" open for the other complete colonoscopy to still be done at the physician's specified later date. When billing with a 52 (reduced services) there is not a plan to complete later. Hopefully this makes sense, let me know if it does not I do not often respond on here. Thanks!
 
My provider used CPT 45385 for procedure, he now wants me to add modifier 53, because he wants to repeat procedure. The cecum was identified by the appendiceal orifice ileocecal valve. The prep was poor. Three small polyps were removed with snare, no other polyps were noted throughout the length of the colon however visualization was limited secondary to the vegetable matter. The colon was decompressed the scope was withdrawn. Can we add modifier 53 if he examined the colon in its entirety to the cecum. Thanks for any help!!!:confused
 
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