Gastroenterology Coding Alert

Don't let the discrepancy between CPT and CMS keep you from payment. Your gastroenterologist started a colonoscopy, but his operational note indicates he wasn't able to inspect all the way to the patient's cecum, the deepest part of the colon. At what point can you consider a colonoscopy complete for coding purposes? You have to know some anatomy to know when a colonoscopy is incomplete. You need to know what the physician intended to view ��" how far did he want to go and how far did he get? And you have to know what your payer is thinking when it sees the term "incomplete." Our experts fill in the details so you can submit clean claims every time. Some Procedures Are Just Lesser, Not Incomplete Definition: A colonoscopy, 45378-45392 (Colonoscopy, flexible, proximal to splenic flexure ...), is an inspection of the whole lower intestine, starting at the rectum and ending at the cecum, where the lower intestine empties into the lower bowel. An incomplete colonoscopy is when a doctor plans a colonoscopy but can't complete it. Watch out: Proctosigmoidoscopy, 45300-45327 (Proctosigmoidoscopy, rigid ...), and sigmoidoscopy, 45330-45345 (Sigmoidoscopy, rigid ...), are lesser procedures that don't intrude as far into the bowel, so you should not confuse them with an "incomplete" colonoscopy. Smart move: When you decide how to code an "incomplete" colonoscopy, consider "the intent of what is to be viewed or biopsied prior to the procedure," suggests Anne Schwartz, coordinator of pediatric gastroenterology and nutrition at Goryeb Children's Hospital at Atlantic Health in Morristown, N.J. So if Schwartz's gastroenterologist never intended to inspect the ascending or transverse colon, she wouldn't code a colonoscopy, for example. She would consider the lesser procedure codes instead. CPT and CMS Don't Agree If you're not coding for a hospital outpatient facility but rather the physician's professional service, CPT says to use modifier 52 (Reduced services) to report an incomplete colonoscopy; CMS says to use modifier 53 (Discontinued procedure) to report a colonoscopy if the physician was unable to view farther into the colon than the splenic flexure. Which you'll use depends on your insurer. CMS Focuses on the Splenic Flexure CMS is fixated on the splenic flexure, the bend that separates the transverse colon from the descending colon. Medicare pays at the rate of a lesser procedure if the colonoscopy doesn't make it past this bend. Tip: Schwartz said she finds an anatomical diagram helpful for visualization when she's coding from an operative report. See diagram on page 3. From the Medicare Claims Processing Manual: "Failure to extend beyond the splenic flexure means that a sigmoidoscopy rather than a colonoscopy has been performed." A sigmoidoscopy is an inspection of the descending colon only. [...]