Wiki Incomplete colonoscopy with biopsy taken

[Deadpd]

The pt had a colonoscopy, a polypectomy was performed. Yet the procedure was incomplete due to poor preparation. Would I put a modifier with the procedure?

"Additional findings: There was solid stool throughout the colon which limited the examination."

 

[daniel]

here, I share this with my team.......... It's in the guidelines as well.



When to use modifier 53 versus modifier 52



Screening/Diagnostic vs Therapeutic



Colonoscopy; to be considered a colonoscopy, the examination must be to the cecum (or to the enterocolic anastomosis if the cecum has been surgically removed).

• Incomplete colonoscopies not reaching the splenic flexure are reported as flexible sigmoidoscopies.
• Incomplete screening or diagnostic colonoscopies that reach beyond the splenic flexure but not to the cecum are reported with modifier 53. This allows future payment for a repeat examination before the usual screening interval.
• Therapeutic colonoscopies that are incomplete (the scope does not reach the cecum during a therapeutic procedure) are reported with modifier 52.

 

[daniel]

This Q&A may help to.

Question: A physician performed a colonoscopy and reached the cecum. The physician took several biopsies but plans to repeat the procedure at a later time due to poor patient preparation. How should this procedure be reported? Should modifier 52 or 53 be appended?



Answer: This procedure would be reported with code 45380, Colonoscopy, flexible; with biopsy, single or multiple. A modifier should not be appended because the complete procedure was performed. The Colonoscopy Decision Tree in the CPT 2021 code set instructs that modifier 53, Discontinued Procedure, should be appended to code 45378, Colonoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure), if the physician were unable to advance the colonoscope to the cecum, and modifier 52, Reduced Services, is appended to therapeutic colonoscopy codes 45379-45398 if the physician was unable to advance the colonoscope to the cecum. In the scenario presented, the cecum was reached; therefore, modifier 52 and modifier 53 would not apply.