Billing Medicare for Failed Colonoscopy
A Medicare covered colonoscopy that is attempted but cannot be completed because of extenuating circumstances is considered to be an incomplete colonoscopy (the inability to advance the colonoscope to the cecum or to the colon-small intestine anastomosis due to unforeseen circumstances). When a covered colonoscopy is next attempted and completed, Medicare will pay for that colonoscopy according to its payment methodology for this procedure, as long as all coverage conditions are met. This applies to both screening and diagnostic colonoscopies. The failed procedure is billed and paid using CPT code 45378, HCPCS code G0105 or G0121, or CPT code 44388, if attempting to perform the colonoscopy through an existing stoma. Modifier “-53” (discontinued procedure) must be appended to any procedure code submitted when billing for a failed colonoscopy attempt.
Applicable Codes for Failed Colonoscopy
If the physician preps the patient for a screening colonoscopy but cannot advance the scope past the splenic flexure due to obstruction, patient discomfort or other complications, consider this as an incomplete/ failed colonoscopy and use following codes. Medicare expects 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.
- CPT code 44388: Colonoscopy through stoma; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)
- CPT code 45378: Colonoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)
- HCPCS code G0105: Colorectal cancer screening; colonoscopy on individual at high risk
- HCPCS code G0121: Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk
- Modifier 53 (Discontinued Procedure): Under certain circumstances, the physician may elect to terminate a surgical or diagnostic procedure. Due to extenuating circumstances or those that threaten the wellbeing of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued. This circumstance may be reported by adding the modifier -53 to the code reported by the physician for the discontinued procedure.
- Applicable diagnosis codes (ICD-10 CM): Z12.11: Encounter for screening for malignant neoplasm of colon and 0: Family history of malignant neoplasm of digestive organs
If the surgeon is able to advance the scope past the splenic flexure, consider the colonoscopy ‘complete’ and report the appropriate code with no modifier appended. In such a case, Medicare will pay the standard reimbursement rate for the coded procedure.
Defining Incomplete/ Failed Colonoscopy
According to Current Procedural Terminology (CPT) instruction, prior to Calendar Year (CY) 2015, an incomplete colonoscopy was defined as a colonoscopy that did not evaluate the colon past the splenic flexure (the distal third of the colon). In CY 2015, the CPT instruction changed the definition of an incomplete colonoscopy to a colonoscopy that does not evaluate the entire colon. Physicians were previously instructed to report an incomplete colonoscopy with 45378 and append modifier 53 (discontinued procedure), which is paid at the same rate as a sigmoidoscopy. Given that the new CPT definition of an incomplete colonoscopy also includes colonoscopies where the colonoscope is advanced past the splenic flexure but not to the cecum, CMS has established new values for incomplete diagnostic and screening colonoscopies performed on or after January 1, 2016. Incomplete colonoscopies are reported with the 53 modifier. Medicare will pay for the interrupted colonoscopy at a rate that is calculated using one-half the value of the inputs for the codes.
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Reference: Medicare Local Coverage Article: A55227
Coding Corner: Coding for an incomplete colonoscopy
