Wiki Documenting "reduced services"


True Blue
Charlotte, NC
Best answers

My doctor did an Upper EGD with biopsy (43239) he states in the note he made it as far as the antrum of the stomach so I added the 52 modifier since he did not complete the EGD into the duodenum.

Does he need to document why he did not scope into the duodenum?

All he states in the note is he found food in the greater curvature of the stomach. He did not state that it procluded him from "finishing" the procedure.

I have one of our A/R reps asking me why I would put the 52 modifier and she wants to know if the doctor should have put a reason he didn't "complete".

So, should he have? I guess, yes. Does he have to? No idea.
My first concern would be why you are using the 52 modifier to begin with? If the physician intended to enter the duodenum when the procedure started and was unable to do so, or decided not to continue after reaching the antrum than you would be using the 53 modifier for a discontinued procedure. The physician DOES have to indicate why he didn't enter into the duodenum and must be specific "the scope was unable to be passed into the duodenum due to ........"
52 would be used if the physcian indicated at the beginning of the procedure he would not be passing the scope beyond the antrum. He must indicate why as well.
Both cases would require op reports when being billed (at least to Medicare) and there is going to be a difference in pay when using 53 over 52.... I usually see a higher payment on the 53 modifier.
That is a good catch on the A/R reps part. :) She is noticing that dictation is missing that should be there. Whenever a physician does not complete an entire procedure he/she must indicate why.
Hope that helps!