New Billing Guidelines for Incomplete Colonoscopies

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.


Sources:

MLN Matters® article MM9317

Chapter 12, Section 30.1 and Chapter 18, Section 60.2 of the Medicare Claims Processing Manual

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Renee Dustman

Renee Dustman

Renee Dustman is executive editor at AAPC. She has a Bachelor of Science degree in Journalism and a long history of writing just about anything for just about every kind of publication there is or ever has been. She’s also worked in production management for print media, and continues to dabble in graphic design.
Renee Dustman

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Renee Dustman is executive editor at AAPC. She has a Bachelor of Science degree in Journalism and a long history of writing just about anything for just about every kind of publication there is or ever has been. She’s also worked in production management for print media, and continues to dabble in graphic design.

5 Responses to “New Billing Guidelines for Incomplete Colonoscopies”

  1. MARY ANN SHUPE says:

    I work as a hospital outpatient coder. Modifier -53 is not used in a hospital setting – should we continue to use -74 modifier as we’ve previously done?

  2. Renee Dustman says:

    Palmetto GBA says:
    Part B Guidelines/Instructions:
    Submit CPT modifier 74 for ambulatory surgery center (ASC) facility charges when the surgical procedure is discontinued after anesthesia is administered
    This modifier may not be submitted by the operating surgeon. Only ASCs should submit this modifier. Surgeons may refer to CPT modifier 53.

  3. Robin Miller says:

    I agree with the above guideline, however no one is giving instructions when a patient is prepped for a Diagnostic/Screening colonoscopy and the scope cannot get past the splenic flexure. Based on the CPT table the correct code would be a Flex Sigmoidoscopy 45330. The CMS guideline does not address these type of procedure. Can you please clarify when a patient is coming in for a Colonoscopy and scope does not reach the splenic flexure.

  4. LAURA GOODRICH says:

    What’s the correct ICD-10 code for Incomplete Colonoscopy?

  5. Rosemarie Cuomo says:

    I have the same question as Robin Miller and would be grateful for a reply.

    Robin Miller says:

    March 14, 2016 at 1:29 pm

    I agree with the above guideline, however no one is giving instructions when a patient is prepped for a Diagnostic/Screening colonoscopy and the scope cannot get past the splenic flexure. Based on the CPT table the correct code would be a Flex Sigmoidoscopy 45330. The CMS guideline does not address these type of procedure. Can you please clarify when a patient is coming in for a Colonoscopy and scope does not reach the splenic flexure

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