Gastroenterology Coding Alert

Gastroenterologists who still report incomplete colonoscopies with the CPT code for flexible sigmoidoscopies (45330) are not accurately coding for the procedure. Although the Health Care Financing Administrations (HCFA) national policy remains to reimburse only at the level of a flexible sigmoidoscopy for such incomplete procedures, gastroenterologists should use the colonoscopy code 45378 with modifier -53 (discontinued procedure) appended to it.

Editors Note: An incomplete colonoscopy occurs when the scope does not advance past the splenic flexure and is caused by an obstructing lesion, unusual anatomy, inadequate bowel preparation or an inexperienced endoscopist.

Variations in Claims Caused
HCFA Policy Change

For years, local Medicare payers required that an incomplete colonoscopy be coded as a flexible sigmoidoscopy. This was supported by HCFAs overall philosophy of paying for the procedure that was performed, though not intended.

But an incomplete colonoscopy is not the equivalent of a flexible sigmoidoscopy in either work or practice expenses, says James Frakes, MD, a gastroenterologist in Rockford, IL, and president of the American Society for Gastrointestinal Endoscopy (ASGE). There is usually extra time and effort with an incomplete colonoscopy, as well as the need for IV sedation or analgesia. The gastroenterologist may even try to insert more than one instrument.

In 1995, Frakes led a somewhat successful effort to get HCFA to clarify and standardize its policy on the procedure. Three years later, however, not all gastroenterologists have gotten the correct coding message regarding incomplete colonoscopies.

At first, HCFA never came out with a directive on the subject, and it was left up to the carriers discretion, says Terry A. Fletcher, CPC, CCSP, a healthcare coding consultant in Laguna Beach, CA. Although the National Correct Coding Initiative now covers the procedure, the problem is that gastroenterologists are still unaware of how to code for it.

Use Specific Code for
Incomplete Colonoscopies

According to the Medicare Carriers Manual Part 3, Chapter 15 (Fee Schedule for Physicians Service), an incomplete colonoscopy is billed and paid using colonoscopy code 45378 with modifier -53 (discontinued procedure). The Medicare physician fee schedule database has specific values for code 45378-53. These values are the same as for code 45330, sigmoidoscopy, [h]owever, code 45378-53 should be used when an incomplete colonoscopy has been done.

In addition to the CPT code, the claim should include the ICD-9 code V64.3 (procedure not carried out for other reasons) and the detailed operative notes, Fletcher recommends.

Interestingly, some local Medicare carriers are now paying for incomplete colonoscopies at a higher level than mandated by HCFA. For example, Fletcher says that Medicare reimburses her California and Arizona gastroenterology practice clients $166 for a correctly coded incomplete colonoscopy (out of a possible $400 for a completed one). Before Frakes efforts in 1995, Medicare reimbursed an incomplete colonoscopy at $45, the same amount paid for a flexible sigmoidoscopy.

Biopsy Increases Level of Reimbursement

When the scope is unable to pass through the splenic flexure, a gastroenterologist may find a polyp, cancer or area of inflammation in the lower part of the colon that needs to be biopsied or removed, according to Frakes.
It happens all the time, agrees Fletcher. The gastroenterologist may biopsy a polyp found in the sigmoid colon, but not be able to advance the scope beyond the ascending colon.

If a biopsy or polypectomy is performed, the level of reimbursement will be higher even though the colonoscopy is still incomplete. In the case of a biopsy, Fletcher advises using code 45380 (colonoscopy with biopsy, single or multiple) with modifier -52 (reduced services). She estimates that Medicare reimburses her California and Arizona clients $333 for such a procedure (out of a possible $500 if the colonoscopy had been completed).

For a polypectomy performed during an incomplete colonoscopy, Fletcher would use codes 45383-45385 (removal of tumors, polyps, or other lesions by various techniques) with the reduced services modifier -52.

Follow-up Colonoscopy Billed at Full Rate

Many times after an incomplete colonoscopy, the gastroenterologist reschedules the patient for a second colonoscopy, which can be billed at the full reimbursement rate. There is no reduction in payment or penalty for a follow-up colonoscopy, which is one reason Medicare payments are reduced so dramatically for incomplete procedures.

HCFAs reasoning is that someone else is going to come back and do a full colonoscopy on the same patient, Frakes says.

Editors Note: Because allowed levels of reimbursement vary from state to state for this procedure, gastroenterologists should contact their local Medicare and private insur-ance carriers to obtain specific policies and practices.