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Incomplete EGD

Robyn Posted Mon 02nd of February, 2015 15:13:42 PM

Endoscope passed over tongue & upon entering the hypopharynx, marked edema is noted. Physician is unable to pass this area into the upper esophageal sphincter. The esophagus was not visualized. Procedure aborted. Should I used 43235-53?

SuperCoder Answered Mon 02nd of February, 2015 16:08:27 PM

Thanks for your question. Reporting instructions for modifier 53; discontinued procedure has been clarified to ensure proper modifier usage. Modifier 53 would be used if the provider terminated the procedure because harm would come to the patient if continued and the provider will try to complete the procedure at a future date. For your scenario, modifier 53 would be appropriate to append to 43235.

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