Wednesday, December 2, 2015

Payment update on colonoscopy discontinued procedure 44388, 45378, G0105 and G0121

Change Request (CR) 9317, from which this article is taken, revises the method for calculating payment for discontinued procedures. New payment rates will apply when
Modifier 53 (discontinued procedure) is appended to codes 44388, 45378, G0105, and G0121

Effective for services performed on or after January 1, 2016, the Medicare Physician Fee Schedule (MPFS) database will have specific values for Current Procedural Terminology (CPT) codes 44388-53; 45378-53; G0105-53; and G0121-53.

GO – What You Need to Do

Make sure that your billing staffs are aware of these revisions for calculating payments for discontinued procedures using Modifier 53. Incomplete colonoscopies are reported with Modifier 53. Medicare will pay for the interrupted colonoscopy at a rate that is calculated using one-half the value of the inputs for the codes.

According to 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 (thedistal third of the 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.

In CY 2015, the CPT instruction changed the definition of an incomplete colonoscopy to a colonoscopy that does not evaluate the entire colon. The 2015 CPT Manual states: “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) has applied specified values in the Medicare

Physician Fee Schedule (MPFS) database for the following codes:

** 44388-53 (colonoscopy through stoma);
** 45378-53 (colonoscopy);
** G0105-53 (colorectal cancer screening; colonoscopy on individual at high risk; and
** G0121-53 (colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk).

Effective for services performed on or after January 1, 2016, the MPFS database will have specific values for the codes listed above. Given that the new CPT definition of an incomplete colonoscopy also include 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 Modifier 53. 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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