tci Outpatient Facility Coding Alert - 2016 Issue 6

Reader Question: Know When to Append 52 vs. 53

Question: Our gastroenterologist performed a diagnostic colonoscopy but was unable to get past the rectum due to a tight surgical colorectal anastomosis. Our gastroenterologist suggested that the patient would need surgery to correct the anastomosis. He also mentioned inadequate preparation for the procedure and discontinued the procedure. He then sent the patient to radiology for a barium enema examination. Can I bill the colonoscopy procedure that our gastroenterologist attempted? If so, should I use modifier 52 or 53? Oklahoma Subscriber Answer: Because the physician started out with the procedure with the intention of performing a complete colon exam, you...

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