Gastroenterology Coding Alert

Question: A Medicare patient came in for a screening colonoscopy. My gastroenterologist performed the procedure, but the patient had prepped very poorly. The doctor wants the patient to come back for another colonoscopy in a year with a better prep. Can we bill this with a modifier so the patient can come in a year from now without having a diagnosis other than screening?

Louisiana Subscriber

Answer: Most coding experts agree that you should append modifier 53 (Discontinued procedure) to the G codes for a screening. Typically, the reimbursement will be the same as a flexible sigmoidoscopy, but using the modifier justifies the patient coming back for a repeat screening.

Medicare has a well-established policy for appending modifier 53 to the code for a diagnostic colonoscopy. But CMS has issued no such guidelines for screenings. An entry for incomplete diagnostic colonoscopy (45378-53) in the Medicare Physician Fee Schedule database indicates the reimbursement for the procedure, but there is no corresponding entry for the screening codes.

Caution: Review the op report before you bill for an incomplete screening colonoscopy. The gastroenterologist may write that it was incomplete because she was unable to advance the endoscope all the way to the cecum. But if the scope goes beyond the splenic flexure, Medicare considers it to be complete.

To further indicate that this was an incomplete screening, submit diagnosis V64.1 (Surgical or other procedure not carried out because of contraindication) with the claim.

--  Clinical and coding expertise for this issue provided by Michael Weinstein, MD, a gastroenterologist in Washington, D.C., and former member of the AMAs CPT Advisory Panel; and Linda Parks, MA, CPC, CMC, CMSCS, an independent coding consultant in Atlanta.