Clear Modifier 52, 53Ambiguity for Incomplete Scope

This year (2011), see to it that you stay away from frequency trap.

Think of a situation where your general surgeon carries out a procedure on a patient who is scheduled and prepared for a total colonoscopy. During the procedure, the physician finds out that owing to unforseen circumstance, he cannot advance the colonoscope beyond the splenic flexure. How should you go about this situation?

Here's what you need to do

You should use the colonoscopy code 45378 (Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen[s] by brushing or washing, with or without colon decompression [separate procedure]) with the proper modifier -- but then which modifier?

Disparate instructions lead to a lot of confusion

For the incomplete colonoscopy scenario, previous editions of CPT instructed you to use modifier 52 (reduced services) to 45378. On the other hand, the Center for Medicare and Medicaid (CMS) instructed you to go for modifier 53 (Discontinued procedure).

Rationale: The agency advised that you use modifier 53 in order to overcome a frequency edit trap. If after coding 45378-52, you had to go back and do a colonoscopy that you coded 45378, you would not get the payments because of the frequency edits.

Here's what you should know

CPT 2011 changes the text note so that it now instructs providers to report an incomplete colonoscopy with modifier 53 and the proper documentation.