Gastroenterology Coding Alert

Question: The surgeon prepares a Medicare patient meeting high-risk criteria for a screening colonoscopy and inserts the scope. Due to extreme patient discomfort and inability to negotiate further, the surgeon decides that he must discontinue the procedure prior to completion. What should I report on the claim?

Washington Subscriber

Answer: You would bill G0105 (Colorectal cancer screening; colonoscopy on individual at high risk) and append modifier 53 (Discontinued procedure).

Why: When your surgeon begins a screening exam for a Medicare patient but cannot advance the scope past the plenic flexure due to obstruction, patient discomfort or other complications, you should append modifier 53 to the appropriate screening exam G code. "This situation parallels those of diagnostic colonoscopies in which the provider is unable to complete the colonoscopy because of extenuating circumstances and must attempt a complete colonoscopy at a later time," explains Medicare policy as outlined in CMS Program Memorandum Transmittal AB-03-114, Change Request 2822, dated Aug. 1, 2003. Don't forget to keep your documentation on hand.

You don't have to worry about reimbursement rate as your surgeon will still receive payment from Medicare for such an "incomplete" colonoscopy -- but at a reduced rate. "When a covered colonoscopy is attempted but cannot be completed because of extenuating circumstances ... Medicare will pay for the interrupted colonoscopy at a rate consistent with that of a flexible sigmoidoscopy as long as coverage conditions are met for the incomplete procedure," according to Transmittal AB-03-114.