Question

To report esophagogastroscopy where the duodenum is deliberately not examined (e.g., judged clinically not pertinent), or because the clinical situation precludes such an exam (e.g., significant gastric retention precludes safe exam of duodenum), append modifier ____ if repeat examination is planned.

a) -32
b) -33
c) -34
d) -35

Answer 1

To accurately report an esophagogastroscopy where the duodenum was not examined, modifier -53 should be used if a repeat examination is planned.

Step-by-step explanation:

To report an esophagogastroscopy where the duodenum is deliberately not examined (e.g., judged clinically not pertinent), or because the clinical situation precludes such an exam (e.g., significant gastric retention precludes safe exam of duodenum), append modifier -53 if repeat examination is planned. This coding is used in situations where a physician may decide not to advance the endoscope into the duodenum due to various clinical reasons or if doing so might pose a risk to the patient. The -53 modifier is attached to the CPT code to indicate that the service was reduced due to extenuating circumstances or that a more extensive procedure was planned but not fully completed due to these reasons.