Modifiers and Medicare in Screening or Diagnosis of Colonoscopy

We know with the legislation that has been passed that all of the (interim) – all of the copays and deductibles have been waived, we know that previously we had screening services that if we went to an ambulatory care center or some other place they would have a 25% copay. That has been waived across the board also.

So what do we do if we have a colonoscopy that we can't finish? Okay. We go to the Medicare Carrier's Manual – Carrier's manual. Chapter 18 is about preventive and screening services. So we have information both in Chapter 12 where we're used to looking but also in Chapter 8 which is all about preventive and screening services.

Now, the most important thing to know once you have a colonoscopy that's not completed is
when was it stopped. Now, depending on (application) with Medicare or other insurances, we're going to look at what modifiers to use, what we really do need to know. And we say “know” in the sense of “know” in the confines of the documentation of the operative notes when was this procedure cancelled, if you will, because maybe they didn't even start.

Feb 27, 2020
Lynn M. Anderanin

So Medicare tells us that we're going to look at a modifier -53 if we have an attempted but
interrupted colonoscopy. They're going to make a payment that is listed on the Medicare Fee Schedule database for that specific modifier.

It is a rate that is less than for a colonoscopy. It is actually that of a flexible sig. And what this
modifier -53 also does is it doesn't start the clock, if you will, you know, the clock. It doesn't say that they've had a successful colonoscopy. It says it was interrupted but therefore they still get their one (technically will be) identified by their list.

So we have a couple of modifiers to look at. We have modifier -52 which is the reduced service.

Now this is something we use in many different areas.

For hospital outpatient reporting of a previously scheduled that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of the anesthesia. That's how that modifier specifically be.

Our modifier -53 – and this is the language from CPT – discontinued extenuating circumstances or those that threaten the well-being of the patient.

Now, we look at this -53 for CMS and it's attached to the surgical code when the procedure was started but has to be discontinued. So it's all about the anesthesia induction.


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