Reporting Diagnostic Endoscopy and Laparoscopy on the same day
If a diagnostic scout endoscopy leads to the performance of a laparoscopic or open procedure, the diagnostic endoscopy may be separately reportable. Modifier 58 may be reported to indicate that the diagnostic endoscopy and non-endoscopic therapeutic procedures were staged or planned procedures.
The medical record must indicate the medical necessity for the diagnostic endoscopy. However, if a scout endoscopic procedure is performed as an integral part of an open procedure, only the open procedure is reportable. If the endoscopy is confirmatory or is performed to assess the surgical field (“scout endoscopy”), the endoscopy does not represent a separate diagnostic or surgical endoscopy.
The endoscopy represents exploration of the surgical field, and should not be reported separately with a diagnostic or surgical endoscopy code.
Reporting Diagnostic Endoscopy and an Open Procedure on the same day
If a scout endoscopic procedure is converted to an open procedure, only the open procedure may be reported. Neither a surgical endoscopy nor a diagnostic endoscopy code should be reported with the open procedure code when an endoscopic procedure is converted to an open procedure.
If a diagnostic endoscopy is the basis for and precedes an open procedure, the diagnostic endoscopy is separately reportable with modifier 58. However, the medical record must document the medical reasonableness and necessity for the diagnostic endoscopy.
Reporting Diagnostic and Surgical Endoscopy on the same day
Surgical endoscopy includes diagnostic endoscopy which is not separately reportable. If a diagnostic endoscopy leads to a surgical endoscopy at the same patient encounter, only the surgical endoscopy may be reported.