New Billing Guidelines for Incomplete Colonoscopies
The Centers for Medicare & Medicaid Services (CMS) has established new values for incomplete diagnostic and screening colonoscopies performed on or after January 1, 2016.
Why the Change?
Prior to 2015, CPT® defined “incomplete colonoscopy” as a colonoscopy that did not evaluate the colon past the splenic flexure (the distal third of the colon). And physicians were instructed to report an incomplete colonoscopy with 45378-53, which was paid at the same rate as a sigmoidoscopy.
For 2015, however, CPT® changed the definition of an incomplete colonoscopy to a colonoscopy that does not evaluate the entire colon. That is, the colonoscope is advanced past the splenic flexure but not to the cecum.
The 2015 CPT® codebook states:
“When performing a diagnostic or screening endoscopic procedure on a patient who is scheduled and prepared for a total colonoscopy, if the physician is unable to advance the colonoscope to the cecum or colon-small intestine anastomosis due to unforeseen circumstances, report 45378 (colonoscopy) or 44388 (colonoscopy through stoma) with modifier 53 and provide appropriate documentation.”
Proper Coding for 2016
New payment rates will apply when modifier 53 Discontinued procedure is appended to CPT®/HCPCS Level II codes:
- 44388 Colonoscopy through stoma; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure);
- 45378 Colonoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure);
- G0105 Colorectal cancer screening; colonoscopy on individual at high risk; and
- G0121 Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk.
Under the Physician Fee Schedule (PFS), Medicare will pay for the interrupted colonoscopy at a rate that is calculated using one-half the value of the inputs for the codes.
MLN Matters® article MM9317
Chapter 12, Section 30.1 and Chapter 18, Section 60.2 of the Medicare Claims Processing Manual