I am still looking for an answer to the incomplete screening colonoscopy when the scope does not reach the splenic flexure. The CMS policy doesn't seem to address this. When inquiring with them, they indicated to referred to the Local
Coverage Article A52378 Billing and Coding: Colorectal Cancer Screening – Medical Policy Article. The article states, "
When a covered colonoscopy is attempted but cannot be completed because of extenuating circumstances, Medicare will pay for the interrupted colonoscopy as long as the coverage conditions are met for the incomplete procedure. (See CMS Publication 100-04,
Medicare Claims Processing Manual, Chapter 18, Section 60.2(A)(1) for additional information.) (See CMS Publication 100-04,
Medicare Claims Processing Manual, Chapter 18, Section 60.2)"
CMS Claims Processing Manual, Chapter 12, Section 30.1 states, "An incomplete colonoscopy, e.g., the inability to advance the colonoscope to the cecum or colon-small intestine anastomosis due to unforeseen circumstances, is billed and paid using colonoscopy through stoma code 44388, colonoscopy code 45378, and screening colonoscopy codes G0105 and G0121 with modifier “-53.” (Code 44388 is valid with modifier 53 beginning January 1, 2016.) The Medicare physician fee schedule database has specific values for codes 44388-53, 45378-53, G0105-53 and G0121-53. An incomplete colonoscopy performed prior to January 1, 2016, is paid at the same rate as a sigmoidoscopy. Beginning January 1, 2016, Medicare will pay for the interrupted colonoscopy at a rate that is calculated using one-half the value of the inputs for the codes"
This document does not go into guidance related to if the scope does not reach the splenic flexure. I understand the decision tree states to use Flexible Sigmoidoscopy coding if the scope does not reach the splenic flexure; however, CMS's policy does not seem to match that.
CMS Claims Processing Manual, Chapter 18 - Preventive and Screening Services, Section 60.2.A.2 states, "When a covered colonoscopy is attempted but cannot be completed because of extenuating circumstances (see chapter 12, section 30.1), Medicare will pay for the interrupted colonoscopy at a rate that is calculated using one-half the value of the inputs for the codes. The MPFS database has specific values for codes 44388-53, 45378-53, G0105-53 and G0121-53. When a covered colonoscopy is next attempted and completed, Medicare will pay for that colonoscopy according to its payment methodology for this procedure as long as coverage conditions are met. This policy is applied to both screening and diagnostic colonoscopies. When submitting a claim for the interrupted colonoscopy, professional providers are to suffix the colonoscopy code with a modifier of -53 to indicate that the procedure was interrupted. When submitting a claim for the facility fee associated with this procedure, ASCs) are to suffix the colonoscopy code with modifier -73 or -74 as appropriate. Payment for covered screening colonoscopies, including that for the associated ASC facility fee when applicable, shall be consistent with payment for diagnostic colonoscopies, whether the procedure is complete or incomplete. Note that Medicare would expect the provider to maintain adequate information in the patient’s medical record in case it is needed by the A/B MAC (B) to document the incomplete procedure. "
Additionally, the email reply I got back from them states,
"Thank you for your e-mail received on August 18, 2021. You wrote to us requesting clarification on MLN MM10937.
When performing a diagnostic or screening endoscopic procedure on a patient who is scheduled and prepared for a total colonoscopy, if the physician is unable to advance the colonoscope to the cecum or colon-small intestine anastomosis due to unforeseen circumstances, report 45378 (colonoscopy) or 44388 (colonoscopy through stoma) with modifier 53 and provide appropriate documentation. The coverage article confirms this.
A covered colonoscopy that is attempted but cannot be completed because of extenuating circumstances is considered to be an incomplete colonoscopy (the inability to advance the colonoscope to the cecum or to the colon-small intestine anastomosis due to unforeseen circumstances). The failed procedure is billed and paid using CPT® code 45378, HCPCS code G0105 or G0121, or CPT® code 44388, if attempting to perform the colonoscopy through an existing stoma. Modifier “-53” (discontinued procedure) must be appended to any procedure code submitted when billing for a failed colonoscopy attempt."
Based off this, I would infer regardless of where the colonoscope ends, it should be reported using the above listed codes instead of the flexible sigmoidoscopy coding.
Respectfully,