Billing Medicare For Failed Colonoscopy

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Billing Medicare For Failed
Colonoscopy
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Billing Medicare For Failed Colonoscopy
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 patients medical
record in case it is needed by the contractor to
document the incomplete procedure.
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Billing Medicare For Failed Colonoscopy

• 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.

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Billing Medicare For Failed Colonoscopy

• 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.
• Medisys Data Solutions is a leading medical
  billing company providing complete billing and
  coding services for various medical billing
  specialties. We hope above article on Billing
  Medicare for Failed Colonoscopy would have
  provided you detailed information for billing
  Medicare. If you are seeking assistance in coding
  for your practice, contact us at
  info_at_medisysdata.com / 888-720-8884

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