Gastroenterology Coding Alert

Question: My doctors have a couple of Medicare patients that they performed a routine low risk screening colonoscopy on, but due to poor prep, visualization was limited.  The cecum was reached and no polyps were found, BUT due to poor visualization the physicians want to recall them in 3-5 years.  My concern is Medicare only covers that procedure every 10 years, so how do we schedule a follow up before the 10 years?  Do we need to bill the current one with a modifier?

Michigan Subscriber

Answer: As per Medicare guidelines, if a screening colonoscopy is not completed due to any extenuating circumstances, you can receive reimbursement for the incomplete procedure as long as other coverage criteria are met. The rate at which Medicare will pay will be consistent to that of a flexible sigmoidoscopy procedure. When your doctors attempt the next colonoscopy, Medicare will pay for this procedure according to its payment methodology if other coverage criteria are being met.

While reporting a claim for the incomplete procedure, it is necessary to use the modifier 53 (Discontinued procedure) to the colonoscopy code that you are billing for the procedure. This will indicate that the screening was interrupted and not completed. You will need to maintain adequate documentation of the patient in order to support your claim for the incomplete procedure.