hema_anan
New
How would you code this scenario?
Patient had initial screening colonoscopy in January. Provider documented that bowel prep was fair and colonoscope was advanced to cecum, and that procedure was completed without difficulty. One of the polyp was removed by snare technique. There was a large flat IC valve polyp that was biopsied but not removed due to patient experiencing excessive discomfort. Provider recommended repeat procedure in 2 months with 2 days of bowel prep.
Patient comes back in March for repeat colonoscopy which is completed with polyp removal.
Would the initial colonoscopy in January be considered as incomplete procedure (modifier 53) since patient experienced discomfort even though scope was advanced to cecum?
Should the repeat procedure be billed as screening turned diagnostic/therapeutic procedure with Z12.11 and polyp dx?
Thank you for any guidance
Patient had initial screening colonoscopy in January. Provider documented that bowel prep was fair and colonoscope was advanced to cecum, and that procedure was completed without difficulty. One of the polyp was removed by snare technique. There was a large flat IC valve polyp that was biopsied but not removed due to patient experiencing excessive discomfort. Provider recommended repeat procedure in 2 months with 2 days of bowel prep.
Patient comes back in March for repeat colonoscopy which is completed with polyp removal.
Would the initial colonoscopy in January be considered as incomplete procedure (modifier 53) since patient experienced discomfort even though scope was advanced to cecum?
Should the repeat procedure be billed as screening turned diagnostic/therapeutic procedure with Z12.11 and polyp dx?
Thank you for any guidance