Wiki Need Help with Screening Colonoscopy done Twice due to Poor Bowel Prep

[elizabeth24]

We are stuck on how to code and/or bill for a procedure or if we can even try and get reimbursed, and we are hoping someone out there can help us.

We had a patient that underwent a screening colonoscopy. The colonoscopy was a complete colonoscopy - the procedure was never terminated - but the physician felt that the colonoscopy was inadequate due to poor bowel prep.

So he recommended the patient come back for a second screening colonoscopy with a 2 day bowel prep before.

Insurance is of course not paying for the second colonoscopy. There is nothing to make it diagnostic.

Does anyone have any idea what to do in this situation?

Thanks!

 

[elaine.pulsepoint@icloud.com]

From the AGA:
If a patient presents for a screening colonoscopy and the scope was advanced to the cecum, but visualization was poor and the physician wants to repeat the procedure in one year, how do we code the first procedure?

Given Medicare's time restriction of two years between two high risk screenings and 10 years between two average risk procedures, if a screening is repeated in one year, it will be denied by Medicare as "not medically necessary." If the physician wants to repeat the procedure within the restricted time, ***the first procedure should be billed with a 53 modifier,*** even though the scope advanced beyond the splenic flexure.

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My Input:
You must append the first colonoscopy that was deemed incomplete due to poor prep with the modifier 53 and the DX code "procedure not carried out for other reasons" in addition to a free text note on the claim that says "poor prep must repeat".

No special modifiers are required on the subsequent, repeat colonoscopy but it doesn't hurt to put a free text note on the claim that says "repeat procedure" and be prepared to appeal any denials because some payer clinical edits will still kick the claim out but you can argue that the first claim was paid at 50% due to your modifier, etc.

If you did not submit the first colon with the appropriate modifier on it, the subsequent colon will deny for frequency exceeded. If this happens, you need to submit a corrected claim to the payer for the original colon and append the modifier, send notes, etc. This will result in a reduced payment on that first colon. You can choose to send the repeat colon w/notes along with this corrected claim, or you can wait until you get the take back on the first colon, then resubmit the repeat colon.

The repeated procedure will pay at 100%

I recommend contacting provider services for guidance on how best to handle their corrections. Sometimes they are very helpful and will let you fax corrections with them on the phone, or sometimes they have a specific form you can fill out and submit for reconsideration.

Good luck!

 

[elizabeth24]

Thanks so much!!! That helped tremendously. We at least know where to start now.