Surgery: Digestive System, Colonoscopy, 45380 (Q&A)

 CPT Assistant, August 2021, Volume 31, Issue 8, page 15

Question:

A physician performed a colonoscopy and reached the cecum. The physician took several biopsies but plans to repeat the procedure at a later time due to poor patient preparation. How should this procedure be reported? Should modifier 52 or 53 be appended?

Answer:

This procedure would be reported with code 45380, Colonoscopy, flexible; with biopsy, single or multiple. A modifier should not be appended because the complete procedure was performed. The Colonoscopy Decision Tree in the CPT 2021 code set instructs that modifier 53, Discontinued Procedure, should be appended to code 45378, Colonoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure), if the physician were unable to advance the colonoscope to the cecum, and modifier 52, Reduced Services, is appended to therapeutic colonoscopy codes 45379-45398 if the physician was unable to advance the colonoscope to the cecum. In the scenario presented, the cecum was reached; therefore, modifier 52 and modifier 53 would not apply.