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Did You Catch This Colonoscopy Change in the MPFS 2023 Proposed Rule?

Published on Fri Oct 14, 2022

Brush up on your 00812 reporting skills to be ready for expanded screening coverage.

The 2023 Medicare Physician Fee Schedule (MPFS) proposed rule indicates there may be changes ahead for screening colonoscopies. These important services typically require sedation or anesthesia, so make sure you don’t miss the potential updates that may affect your claims.

Understand Importance of ‘Follow-On Screening Colonoscopy’

In the MPFS 2023 proposed rule, “there is good news regarding expanding coverage for colorectal cancer screening,” says Kelly D. Dennis, MBA, ACS-AN, CANPC, CHCA, CPC, CPC-I, owner of Perfect Office Solutions in Leesburg, Florida.

You can find the relevant section of the 2023 MPFS proposed rule at www.federalregister.gov/d/2022-14562/p-1482. The most relevant points from the proposed rule are below.

Age: Some colorectal cancer (CRC) screenings currently limit coverage to patients 50 and older. Expect to see this change to 45 years of age. You can learn more about these screenings in the Medicare National Coverage Determinations (NCD) Manual, Section 210.3 (www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs). Note that screening colonoscopy does not have a minimum age requirement under Medicare coverage, and that is likely to remain the same.

Expanded screening definition: Medicare plans to expand the definition of CRC screenings. They may soon include “follow-up screening colonoscopy after a Medicare-covered noninvasive stool-based screening test that returns a positive result,” Dennis says. Previously, Medicare viewed these tests as diagnostic colonoscopies, the MPFS proposed rule states. But the healthcare community now has a consensus that the follow-up colonoscopy is integral to a complete screening.

Patient’s cost: “Beneficiary cost sharing for the initial screening stool-based test and the follow-on screening colonoscopy test would not apply, and … they are both tests paid at 100 percent (no applicable copayment percentage) as specified screening services,” the proposed rule states. One goal of this change is to remove cost barriers that may have discouraged patients from getting the follow-on colonoscopy. Currently, normal cost-sharing rules apply to the follow-on colonoscopies because they are categorized as diagnostic.

Frequency: Screening colonoscopy frequency limitations “would not apply in the instance of a follow-on screening colonoscopy test after a positive result from a Medicare covered stool-based test,” the proposed rule states.

Same-encounter tissue removal: When the colonoscopy provider decides to remove tissue during the screening colonoscopy, the phased-in Medicare payment percentages finalized in the 2022 MPFS final rule come into play. “When the follow-on screening colonoscopy includes the removal of tissue or other related services during the same clinical encounter the beneficiary coinsurance will be reduced over time from 15 percent for services furnished during CY 2023 through CY 2026 to 10 percent for services furnished during CY 2027 through 2029 to zero percent beginning in CY 2030 and thereafter,” the 2023 proposed rule states.

Know How to Code Anesthesia for Screening Colonoscopy

Assuming Medicare finalizes these changes, you need to be sure the anesthesia and colonoscopy providers you work with are aware of the updates. The patient’s chart needs to correctly identify whether the patient is having a screening or diagnostic colonoscopy (or screening turned diagnostic) so you can report the anesthesia correctly.

For a screening colonoscopy, you should report the anesthesia service using 00812 (Anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum; screening colonoscopy). Medicare waives the coinsurance and deductible, according to Medicare Claims Processing Manual, Chapter 18, Section 1.2 (www.cms.gov/files/document/r10818cp.pdf).

When a screening becomes a diagnostic colonoscopy at the same session, you should report 00811 (… not otherwise specified) for the anesthesia service and append modifier PT (Colorectal cancer screening test; converted to diagnostic test or other procedure), the Medicare Claims Processing Manual states.

For the ICD-10-CM code, you’ll most likely report Z12.11 (Encounter for screening for malignant neoplasm of colon), says Dennis. Some payers “may prefer to have the screening moved to the secondary diagnosis after a primary finding” like a colon polyp, she adds.