New Guidelines for Coding Incomplete Colonoscopies
New values for incomplete colonoscopies (diagnostic and screening) that are performed on or after January 1, 2016 have been established by the Center for Medicare & Medicaid Services (CMS).
Prior to 2015, CPT(R) defined ?incomplete colonoscopy? as a colonoscopy that did not evaluate the colon past the splenic flexure (the distal third of the colon). Hence, physicians were instructed to report an incomplete colonoscopy with 45378 appended with modifier 53, which was paid at the same rate as a sigmoidoscopy.
For 2015, however, CPT(R) 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(R) codebook stated:
?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.?
Therefore in accordance with the change in CPT Manual language, the Centers for Medicare and Medicaid Services (CMS) have applied specified values in the Medicare Physician Fee Schedule (MPFS) database for the following codes:
Proper Coding for 2016
New payment rates will apply when modifier 53, discontinued procedure, is appended to CPT(R)/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.
CMS has established new values for incomplete diagnostic and screening colonoscopies performed on or after January 1, 2016. Incomplete Colonoscopies are reported with Modifier 53. 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.