Monday, August 10, 2015

Difference and Use of Modifier 52 and 53 for GI procedure



QUESTION: Is there a difference regarding the use of modifiers 52 and 53 with regards to upper and lower endoscopic procedures?

ANSWER: Yes.

  • EGD procedures: To report esophagogastroscopy where the duodenum is deliberately not examined (e.g., judged clinically not pertinent) or because significant situations preclude such exam (e.g., significant gastric retention precludes safe exam of duodenum), append modifier 52, if repeat examination is not planned, or modifier 53, if repeat examination is planned.

              • Example: EGD is performed and a tube is placed into the stomach. The duodenum is not examined and there is no plan to perform repeat EGD to examine the duodenum. Report procedure with modifier 52.
              • Example: EGD is performed for evaluation of GI bleeding; the stomach is full of blood and the duodenum is not examined. Plan to control bleeding, lavage stomach and repeat upper endoscopy. Report procedure with modifier 53.

  • Colonoscopy procedures: 


• When performing a diagnostic or screening endoscopic procedure on a patient who is scheduled and prepared for a total colonoscopy, if the physician is unable to advance the colonoscope to the cecum or colon-small intestine anastomosis due to unforeseen circumstances, report 45378 (colonoscopy) or 44388 (colonoscopy through stoma) with modifier 53 and provide appropriate documentation.

• If a therapeutic colonoscopy (44389-44407, 45379, 45380, 45381, 45382, 45384, 45388,45398) is performed and does not reach the cecum or colon-small intestine anastomosis, report the appropriate therapeutic colonoscopy code with modifier 52 and provide appropriate documentation.

QUESTION: Could you provide some examples of how to use and report modifiers 52 and 53 with regards to lower endoscopic procedures?

ANSWER: Yes.

Example: Colonoscopy done for evaluation of iron deficiency anemia. The scope was passed beyond the splenic flexure, but not to the cecum or colon-small intestine anastomosis, because of inadequate prep. The physician indicates that the patient will be brought back for repeat procedure after re-prep tomorrow. Since the exam was incomplete for unforeseen circumstances, and was a diagnostic (not therapeutic) procedure, the patient is returning for complete colonoscopy and modifier 53 should be added to 45378.

Example: 70-year-old male undergoing high risk screening due to personal history of transverse colon cancer. The scope was advanced to the ascending colon, but the prep was incomplete and the examination could not be completed. The physician plans to try again after repeat prep. Modifier 53 would be added to 45378 for the incomplete first attempt. If the second attempt is complete and no lesions are biopsied or removed, report G0105 for the subsequent procedure.

Example: 65-year-old female, asymptomatic, undergoing screening colonoscopy. The scope was advanced to the cecum, but prep is incomplete and visibility was not acceptable, thus adequate screening could not be completed. The patient is returning for re-evaluation after repeat prep. Modifier 53 would be added to 45378 for the incomplete first attempt. If the second attempt is complete and no lesions are biopsied or removed, report G0121 for the subsequent procedure.

Example: 54-year-old undergoing screening colonoscopy. Obstructing mass found in the transverse colon, which prevented examination of the right colon. Biopsies were taken. Modifier 52 and either modifier PT (if a Medicare beneficiary) or 33 (if a commercial, Medicaid, Tricare patient) would be added to 45380. This indicates the procedure was intended to be screening; but once a biopsy was performed it became therapeutic, and as it was incomplete, modifier 52 is reported.

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