tci General Surgery Coding Alert - 2014 Issue 11

Reader Question: Pick Best Modifier for Return to Surgery

Question: A Medicare patient returned to the endoscopy lab to control a bleeding polypectomy site in the ascending colon after a colonoscopy performed the preceding day. The same physician performed both procedures. Which is the best code and modifier combination to report this? Virginia Subscriber Answer: You should use code 45382(Colonoscopy, flexible, proximal to splenic flexure; with control of bleeding [e.g., injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator]) for the colonoscopy procedure. Combine it with modifier 78 (Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following...

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