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Incomplete Colonoscopy: Modifier 52 or 53?

svjai1116

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I'm receiving contradictory guidance on which modifier to use when a gastroenterologist does an incomplete colonoscopy. Should I use modifier 52 or 53?

Chart details :

He was brought into the endoscopy suite and placed on the stretcher in the left lateral decubitus position. He had taken an outpatient bowel prep of nulytely the day prior. Under continuos EKG, blood, and pulse oximetry monitoring, he was given intravenous general by our Anesthesiology dept.

Rectal exam was preformed and demonstreted large external hemorrhoids, tight sphincter tone, no palpable masses, no fissures, no fistulas. The videoendoscope was passed per anus into the rectum slowly traversing the rectum into the sigmoid colon. There did appear to be a small polyp and then immedeately after this was a large mass. This was an obstructing mass that did not permit the pediatric scope to pass through and because of this, I was unable to see the remaining portion of the colon. Multible biopsies were obtained and i sent them for frozen section. The procedure was terminated and the patient was taken to the recovery room in satisfactory condition and surgery would be planned for the very near future.


Please let me know the correct one...

Thanks

Jayamuruhan
 

raghu.kurna

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hi jayamurugan, as per your chart patient has given general anesthesia, so my recommendation would be you can append 53 mod. not 52 mod.
 
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53 modifier

You use a -53 modifier when the procedure had to be discontinued ... as in this case.

You use a -52 modifier when you know in advance that you will not be performing the entire procedure, for example, a patient with a previous surgery who now only has a portion of colon remaining.

Hope that helps.

F Tessa Bartels, CPC, CEMC
 

cingram

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I really hate this everyone misuses modifier -53. If you read the description of modifier -53 it says that it is for a terminated procedure becase it THREATENED THE WELL-BEING OF THE PATIENT. Modifier 52 says a servide is reduced or eliminated at the physicians discretion. and in this case since the patient was in no danger to his well being it was just that the obstruction did not allow the dr to see the rest of the colon and unable to go any further it should be -52 not -53 I would deny these all the time when I was a claims processor and we would have to request medical records because if the patients well-being was not in danger it is an inappropriate use of modifier -53 when it should be -52 and they both pay the same. Read your modifier descriptions it will say all of this. But also there are modifiers -73 and -74 which are for hospital outpatient and ASC procedures that are discontinued.
 
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Exactly as worded in CPT

Here is the description of Modifier 53 exactly as printed in the 2012 CPT professional edition published by the AMA (appendix A, page 568)

53 Discontinued Procedure: Under certain circumstances, the physician may elect to terminate a surgical or diagnositc procedure. Due to extenuating circumstances or those that threaten the well being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued. (emphasis added by FTB)

There's more but this is the key. The little word "or" means that there is NO requirement for the circumstances to threaten the well being of the patient.

Hope that helps.

F Tessa Bartels, CPC, CEMC
 

MC1260

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52 vs 74

I struggle with that too. I recently started coding Endoscopies at the hospital and was told to use 74. but I still question it
 

Coding Chick

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Modifier 52 reduced services

When coding colonoscopies a complete colonoscopy must reach the cecum, in this case it's incomplete which results in modifier 52. When using modifier 53 in colonoscopies it should be used when the procedure is aborted for incomplete prep or questionable health status of the patient. The doctor attempted to complete but was still able to get biopsies.
 

abradburn

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Cpt code for colonoscopy not going past rectum

Hello, I am looking for opinions on how to charge for a screening colonoscopy that doesn't advance past the rectum? Does anyone have any opinions on which CPT code would be best used here?

Thank you!
 

SaritaJP21

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52 vs 53

Here 53 modifier is preferable, as provider is not able to do complete colonoscopy procedure due to obstruction.This should not be considered as reduced service.Provider is discontinuing due to patient's obstructive mass and if he/she continue it may lead to bleeding.
 

saket1577

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52 modifier

Hi,

According to me You can go with 52 modifier because there is large mass and it is obstructing that , so physician has decided to stop the scope procedure.


regards,
Saket
 
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Here is the long description I got for modifier 53

-53 Discontinued Procedure: Under certain circumstances, the physician or other qualified health care professional may elect to terminate a surgical or diagnostic procedure. Due to extenuating circumstances or those that threaten the well being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued. This circumstance may be reported by adding modifier 53 to the code reported by the individual for the discontinued procedure. Note: This modifier is not used to report the elective cancellation of a procedure prior to the patient's anesthesia induction and/or surgical preparation in the operating suite. For outpatient hospital/ambulatory surgery center (ASC) reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for ASC hospital outpatient use).

I almost want to say code for the Sigmoidoscopy because he did not even get pass the hepatic flexure. (just another option)

I have always used -74 modifier on my terminated colonoscopies if an obstructive mass has been found or the physician can not proceed further, but I bill out for ASC only.
 

Sbisc723

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ASC modifier

What would the ASC modifier be on a repeat colonoscopy? The patient has Horizon BCBSNJ. They are not recognizing the -74 modifier
 
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