When to use modifier 53 for colonoscopy?
Asked by: Carmela Braun | Last update: August 24, 2025Score: 4.7/5 (72 votes)
When should modifier 53 be used?
CPT modifier 53 for discontinued procedure indicates that a surgical or diagnostic procedure was started but discontinued.
Is modifier 52 or 53 for incomplete colonoscopy?
Incomplete colonoscopies are reported with the 53 modifier.
What is the modifier for a colonoscopy?
For example, if a physician performing a screening colonoscopy on a patient with commercial insurance finds and removes a polyp with a snare, use CPT code 45385 and append modifier 33 to the CPT code. If the patient is a Medicare beneficiary, use CPT code 45385 with modifier PT.
Why is a diagnostic colonoscopy not covered by insurance?
Soon after the ACA became law, some insurance companies considered a colonoscopy to no longer be just a “screening” test if a polyp was removed during the procedure. It would then be a “diagnostic” test, and would therefore be subject to co-pays and deductibles.
Colonoscopy Decision Tree | Modifier 52 & 53| Beyond Splenic flexure |Dr Rams Medical Coding Academy
What is the difference between preventive colonoscopy and diagnostic colonoscopy?
Diagnostic colonoscopies, also referred to as follow-up or surveillance colonoscopies, are different from screening colonoscopies since such procedures are provided when there is a greater probability of cancer development or if there is evidence that colorectal cancer might be present.
Why does Medicare not pay for colonoscopy?
Medicare Part B (Medical Insurance) covers colonoscopy screenings once every 24 months if you're at high risk for colorectal cancer. If you aren't at high risk, Medicare covers the test once every 120 months or 48 months after a previous flexible sigmoidoscopy.
How to bill for a colonoscopy?
Colonoscopy codes are listed in the digestive section of CPT, codes 45378–45398 (or codes 44388–44408, if performed through a stoma rather than the anus). CPT code 45378 is the base code for a colonoscopy without biopsy or other interventions.
What is the modifier 53 for 45378?
The failed procedure is billed and paid using CPT® code 45378, HCPCS code G0105 or G0121, or CPT® code 44388, if attempting to perform the colonoscopy through an existing stoma. Modifier “-53” (discontinued procedure) must be appended to any procedure code submitted when billing for a failed colonoscopy attempt.
When to use kx modifier for colonoscopy?
Modifier KX was published in Medicare's Med-Learn Matters Article, MM13017, addressing modifier KX. Medicare indicates the following: "Attach the KX modifier to a screening colonoscopy code to indicate such service was performed as a follow-up screening after a positive result from a stool-based test.”
What is the difference between modifier 52 and 53?
Know your choices: You might use modifier 52 (Reduced services), or modifier 53 (Discontinued procedure), or you might use a different code that accurately describes the work completed.
What constitutes an incomplete colonoscopy?
An incomplete colonoscopy occurs when the health care provider is not able to advance the colonoscope through the entire colon to the cecum (a pouch that connects the colon to the small intestine).
Do you need a modifier with EGD and colonoscopy?
We would report the 51 modifier to describe multiple procedures in a different family of endoscopy for colonoscopy (i.e., 45385) and EGD (45239-51). An effective Modifier 59 Coding tip is to use your Box 19 comment /claims narrative field to show this combination of codes should not be bundled.
What is the difference between modifier 52 and 53 for colonoscopy?
I. Modifier -52 is used to report “reduced services.” II. Modifier -53 is used to report “discontinued procedure.” (For outpatient/ASC facility charges, see Coding Policy 39.0.)
How do I know which modifier to use?
The correct modifier to use is determined by payor preference. There can be instances where a CPT code is further defined by an HCPCS modifier, for example, to describe the side of the body the procedure is performed on, such as left (modifier -LT) or right (modifier -RT).
When should modifier 52 not be used?
Modifier -52 should not be used if there is another specific procedure code that appropriately describes the lesser or reduced service that was actually performed; the other procedure code is the most appropriate code and should be reported.
When can you use modifier 53?
Appropriate use modifier 53:
Bill modifier 53 with the CPT code for the service furnished. This modifier is used to report a service or procedure when the service or procedure is discontinued after anesthesia is administered to the patient.
Why isn't a diagnostic colonoscopy covered by insurance?
Your insurance should cover 100% of the costs, so you will not need to pay. If your doctor removes a polyp during the test, it becomes a DIAGNOSTIC COLONOSCOPY. This means your insurance may not cover the cost. Your care team will let you know after if they find any polyps.
What qualifies as a screening colonoscopy?
Screening Colonoscopy
A colonoscopy is considered screening when: You've had no lower gastrointestinal signs or symptoms before the colonoscopy. No polyps or masses are found during the colonoscopy. There's no family history of polyps or colon cancer.
How do you refer for a colonoscopy?
You may be referred to hospital for further tests such as a colonoscopy, if you've visited your GP with symptoms of bowel cancer or if your screening test found blood in your poo. This is to find out what is causing your symptoms.
What is the policy for colonoscopy?
Colonoscopies. Medicare covers screening colonoscopies once every 24 months if you're at high risk for colorectal cancer. If you aren't at high risk, Medicare covers the test once every 120 months, or 48 months after a previous flexible sigmoidoscopy. There's no minimum age requirement.
What is the item code for colonoscopy?
Items 32222-32226 and 32228 provide for diagnostic colonoscopy when claimed alone. Where a polyp or polyps are removed during the colonoscopy, item 32229 should also be claimed in association with the appropriate colonoscopy item.
What are the new guidelines for colonoscopy?
The US Preventive Services Task Force (Task Force) recommends that adults age 45 to 75 be screened for colorectal cancer. The decision to be screened between ages 76 and 85 should be made on an individual basis. If you are older than 75, talk to your doctor about screening.
What is the loophole in a Medicare colonoscopy?
For many years, Medicare beneficiaries were subject to financial surprise bills when their screening colonoscopy required polyp removal and the screening was classified as therapeutic. In 2020, Congress finally closed this financial loophole by phasing out the coinsurance between 2022 and 2030.
Is colonoscopy covered under Part A or B Medicare?
Colonoscopy is a preventive service covered by Part B. Medicare pays all costs, including the cost of anesthesia, if the doctor or other provider who does the procedure accepts Medicare assignment.