Wiki Colonoscopy

[dgarrett10]

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 The colon was decompressed the scope was withdrawn.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

 

[Peterk50]

There are a number of things that play into the colonoscopy. You cannot use modifier 53 if it is not documented that the procedure was aborted or had not gone all way to cecum. If the patient came was coming in initially for colonoscopy you can bill as a wellness turned diagnostic. If the patient or the patient family has history of colon cancer or polyps you can use those DX. hope this helps.