Gastroenterology Coding Alert

Don't let the discrepancy between CPT and CMS keep you from payment.

Your gastroenterologist started a colonoscopy, but his operational note indicates he wasn't able to inspect all the way to the patient's cecum, the deepest part of the colon. At what point can you consider a colonoscopy complete for coding purposes?

You have to know some anatomy to know when a colonoscopy is incomplete. You need to know what the physician intended to view ��" how far did he want to go and how far did he get?

And you have to know what your payer is thinking when it sees the term "incomplete."

Our experts fill in the details so you can submit clean claims every time.

Some Procedures Are Just Lesser, Not Incomplete

Definition: A colonoscopy, 45378-45392 (Colonoscopy, flexible, proximal to splenic flexure ...), is an inspection of the whole lower intestine, starting at the rectum and ending at the cecum, where the lower intestine empties into the lower bowel.

An incomplete colonoscopy is when a doctor plans a colonoscopy but can't complete it.

Watch out: Proctosigmoidoscopy, 45300-45327 (Proctosigmoidoscopy, rigid ...), and sigmoidoscopy, 45330-45345 (Sigmoidoscopy, rigid ...), are lesser procedures that don't intrude as far into the bowel, so you should not confuse them with an "incomplete" colonoscopy.

Smart move: When you decide how to code an "incomplete" colonoscopy, consider "the intent of what is to be viewed or biopsied prior to the procedure," suggests Anne Schwartz, coordinator of pediatric gastroenterology and nutrition at Goryeb Children's Hospital at Atlantic Health in Morristown, N.J.

So if Schwartz's gastroenterologist never intended to inspect the ascending or transverse colon, she wouldn't code a colonoscopy, for example. She would consider the lesser procedure codes instead.

CPT and CMS Don't Agree

If you're not coding for a hospital outpatient facility but rather the physician's professional service, CPT says to use modifier 52 (Reduced services) to report an incomplete colonoscopy; CMS says to use modifier 53 (Discontinued procedure) to report a colonoscopy if the physician was unable to view farther into the colon than the splenic flexure. Which you'll use depends on your insurer.

CMS Focuses on the Splenic Flexure

CMS is fixated on the splenic flexure, the bend that separates the transverse colon from the descending colon. Medicare pays at the rate of a lesser procedure if the colonoscopy doesn't make it past this bend.

Tip: Schwartz said she finds an anatomical diagram helpful for visualization when she's coding from an operative report. See diagram on page 3.

From the Medicare Claims Processing Manual: "Failure to extend beyond the splenic flexure means that a sigmoidoscopy rather than a colonoscopy has been performed." A sigmoidoscopy is an inspection of the descending colon only.

CMS does advise using code 45378-53 if a colonoscopy was intended "because other Medicare physician fee schedule database indicators are different for codes 45378 and 45330" (www.cms.hhs.gov/manuals/downloads/clm104c12.pdf).

Know your payer: Remember, for Medicare and payers that follow Medicare guidelines, you should append modifier 53 to 45378 (... diagnostic, with or without collection of specimen[s] by brushing or washing, with or without colon decompression [separate procedure]) for an incomplete colonoscopy. On the other hand, CPT instructs you to report an incomplete colonoscopy by attaching modifier 52 to the appropriate colonoscopy code (for example, 45378). So you must find out what your payers prefer.

Did it help the patient? "If a therapeutic service (such as a biopsy or polypectomy) was performed and the procedure was incomplete then the appropriate CPT service code (such as 45380, ... with biopsy, single or multiple) would be used with modifier 52 appended," says Michael Weinstein, MD, a gastroenterologist in Washington, D.C. and former member of the AMA's CPT Advisory Panel. You'll want to send along documentation of what the physician did before cutting the procedure fee short, he said.

Don't Use Modifier 76

If the incomplete colonoscopy is attempted and another is completed the same day, just code the completed procedure, Weinstein says.

You should not append modifier 76 (Repeat procedure by same physician).

"I have not ever used or seen that modifier used for GI procedures," he said. "Maybe that is unfair but it is no different than the rule which says you cannot bill for a therapeutic service to fix a problem you caused."

Payers Treat Screenings the Same

Incomplete colonoscopies for colon cancer screenings are handled the same way, says Jan Rasmussen, CPC, ACS-GI, ACS-OB, in her Coding Institute audio presentation, "Best Practices for Lower GI Endoscopy Coding" (www.audioeducator.com).

If you report a screening with HCPCS code G0105 (Colorectal cancer screening; colonoscopy on individual at high risk) or G0121 (Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk) with a modifier 53, payers will reimburse it "at the same rate as an incomplete diagnostic colonoscopy, coded as 45378 with the 53 modifier," she says.