ColonoscopyThe purpose of screening colonoscopy is to detect and remove early cancerous or precancerous lesions. While Medicare beneficiaries without high risk factors are eligible for colonoscopy screening every 10 years, beneficiaries at high risk for developing colorectal cancer are eligible for screening once in every 24 months. Failed or incomplete colonoscopies are also common. Factors that contribute to an incomplete colonoscopy include prior abdominal surgeries resulting in adhesions, severe diverticular disease, a colon with many twists, and patient discomfort. Though primary-care doctors and general surgeons perform these vitally important screenings, gastroenterologists perform more colonoscopies that can detect and save a patient from cancer. Gastroenterology medical billing also involves submitting medical claims for these incomplete colonoscopies.

For these specialists, it is very important to be aware of the latest medical billing and coding updates and use proper modifiers and CPT codes for on-time reimbursement. In response to a change in the definition of colonoscopy in the 2015 CPT manual, the payment for this screening was also increased.

Before 2015, this failed screening was defined as a colonoscopy that did not evaluate the colon past the splenic flexure. Physicians were also instructed to report an incomplete colonoscopy with CPT code 45378 with modifier 53 and the payment rate was the same as that for a sigmoidoscopy.

In CY 2015, the definition of an incomplete colonoscopy was changed to a colonoscopy that does not evaluate the entire colon. The 2015 CPT Manual states that “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.”

And now it is clear that new payment rates will apply when modifier 53 Discontinued procedure is appended to these 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

Earlier, the American Gastroenterological Association had reported that beginning January 1, 2016, Medicare will pay for an incomplete colonoscopy reported with the 53 modifier at “one half the value of the inputs for the corresponding codes.”