Coding for “Incomplete” Colonoscopy
In some cases, a provider may plan to provide a colonoscopy (screening or diagnostic) but, due to unforeseen circumstances, may not be able to complete the procedure.
When reporting services to Medicare, if the provider advances the scope past the splenic flexure, you should consider a screening colonoscopy to be “complete,” and report the appropriate screening code (G0105 Colorectal cancer screening; colonoscopy on individual at high risk or G0121 Colorectal screening; colonoscopy on individual not meeting criteria for high risk, depending on the patient’s risk factors) with no modifier appended. Medicare will pay the standard reimbursement rate for the coded procedure.
But, if the physician preps the patient for a screening colonoscopy and does not advance the scope past the splenic flexure due to obstruction, patient discomfort, or other complications, you should append modifier 53 Discontinued procedure to G0105/G0121, as appropriate, to report an “incomplete” colonoscopy.
The physician will receive Medicare payment for the attempted colonoscopy, at a reduced rate. “When a covered colonoscopy is attempted but cannot be completed because of extenuating circumstances … Medicare will pay for the interrupted colonoscopy at a rate consistent with that of a flexible sigmoidoscopy as long as coverage conditions are met for the incomplete procedure.” Additionally, Medicare “would expect the provider to maintain adequate information in the patient’s medical record in case it is needed by the contractor to document the incomplete procedure.”
Source: CMS Program Memorandum Transmittal AB-03-114, Change Request 2822.
Note that CMS directions for reporting an incomplete colonoscopy differ from those stipulated by the AMA. The CPT® codebook instructs, “For an incomplete colonoscopy [e.g., the scope does not progress beyond the splenic flexure], with full preparation for a colonoscopy, use a colonoscopy code with the modifier 52 [Reduced services] and provide documentation.” Some non-Medicare payers may follow CMS guidelines for an incomplete colonoscopy, while others may adhere to CPT® instructions; check with individual third-party payers for their recommendations.
Reporting an incomplete screening should not trigger Medicare frequency limitations or affect your ability to collect appropriate reimbursement for a subsequent complete examination. CMS Transmittal AB-03-114 instructs, “It is not appropriate to count the incomplete colonoscopy toward the beneficiary’s frequency limit for a screening colonoscopy because that would preclude the beneficiary’s being able to obtain a covered completed colonoscopy…. If coverage conditions are met, Medicare pays for both the uncompleted colonoscopy and the completed colonoscopy whether the colonoscopy is screening in nature or diagnostic.”