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Tara0513

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Here is my dilemma... I have always been under the assumption that during a colonoscopy if the physician reaches the cecum regardless if the prep was poor or not, it is considered a complete colonoscopy:

"The procedure, indications, preparation and potential complications were explained to the patient, who indicated understanding and signed the corresponding consent forms. Diagnostic type colonoscopy. IV anesthesia Continuous pulse oximetry, blood pressure, and cardiac monitoring was done. Supplemental oxygen was used. The quality of preparation was good. Patient was placed in left lateral decubitus position. Following a digital exam, the colonoscope was introduced through rectum and advanced under direct visualization until cecum and terminal ileum was reached The cecal sling folds were seen. The appendiceal orifice and the ileo-cecal valve were identified. The colonoscope was retroflexed within the rectum. Careful visualization was performed as the instrument was withdrawn. Patient tolerance to procedure was good. The procedure was difficult due to poor prep and vegetable matter. Digital exam was normal with the following findings: hemorrhoids. The colonoscope was withdrawn and the procedure was terminated due to scope clogging.. A time out to confirm patient's name, status, planned procedure and physicians involved was performed with the endoscopy technician, anesthesia provider and endoscopist present prior to beginning the procedure"

Patient is now being brought back in December for another colonoscopy. They have Horizon BCBS of NJ. How should I bill??????
 
"procedure was terminated due to scope clogging"

Because the doctor terminated the procedure and wants to repeat within a year, we have been billing:

Z53.8 Procedure and treatment not carried out for other reasons

45378 -53 Professional clm
45378 -74 ASC/facility claim

And in the notes for the claim, I add "procedure was terminated due to poor bowel prep."

My understanding is, if the physician makes it to the cecum, that is just the difference between billing an incomplete coli and a Flex sig. Once the physician goes past the Splenic flexure, it can no longer be billed as a Flex Sig.

I hope this helps.
 
Thank you for your answer, but the physician made it all the way to the cecum, and wants to bring the patient back in with a better prep. Do I still use the 53 modifier?
 
Last edited:
Hi, I hope this helps. I had scope training through NAMAS (National Alliance of Medical auditing specialists. I am AAPC and NAMAS certified. The provider would use a modifier 53 since they plan to reschedule. A 52 would be used if they didn't reschedule the procedure. In the comment section for your 45378- be sure to note poor bowel prep. It is still a complete scope but if the provider repeats and doesn't have an explanation for performing 2 in a short time frame you can get a denial for a duplicate or procedure being performed to soon. You will still use the Z code to show it was stopped.

Mooney CPC, CEMA
 
Hi good day, I hope this message finds you well.

the colonoscope was inserted through the anal canal and could be advanced only to mid sigmoid colon due to presence of brown hard stool. Careful withdrawal was done with retroflexion view of the rectum

im quite confused if I should use 45330 since it reached only sigmoid colon, or still 45378 with appended modifier 53. And I assigned pdx pre-op dx.

Thank you, looking forward for further enlightenment.
 
Hi Paul, we have been following the guidance from the AGA and billing 45378 w/ modifier 53. I copied the reference and the link is below. Hope this helps.

"If a patient is scheduled for a screening colonoscopy and because of a poor prep the scope cannot be advanced beyond the splenic flexure, do I code the procedure as a flexible sigmoidoscopy? Accordion Toggle
No. Per Medicare guidelines, the procedure should be codes as a colonoscopy with a 53 modifier, which will pay a partial fee and allow you to repeat the procedure within the restricted time period and get full payment for the second procedure. Even if the scope was advanced beyond the splenic flexure, but the visualization was poor and the physician wants to repeat the procedure within the restricted time period, add the 53 modifier.
"

 
jrmurphy2015 said:
Hi Paul, we have been following the guidance from the AGA and billing 45378 w/ modifier 53. I copied the reference and the link is below. Hope this helps.

"If a patient is scheduled for a screening colonoscopy and because of a poor prep the scope cannot be advanced beyond the splenic flexure, do I code the procedure as a flexible sigmoidoscopy? Accordion Toggle
No. Per Medicare guidelines, the procedure should be codes as a colonoscopy with a 53 modifier, which will pay a partial fee and allow you to repeat the procedure within the restricted time period and get full payment for the second procedure. Even if the scope was advanced beyond the splenic flexure, but the visualization was poor and the physician wants to repeat the procedure within the restricted time period, add the 53 modifier.
"

Click to expand...

Do you use any modifier when the exam is terminated at the cecum , and doctor documented poor preparation and will repeat colonoscopy in 3 to 6 months?
 
What would happen if the previous procedure stated poor prep but was done by a different provider, so you don't have access to their billing information, and it turns out they didn't put the 53 mod. So, Medicare denies the claim. Has anyone successfully appealed Medicare for the repeat procedure?
 
such78 said:
Do you use any modifier when the exam is terminated at the cecum , and doctor documented poor preparation and will repeat colonoscopy in 3 to 6 months?
Click to expand...
I'd also like to know the answer to this question please....can we use dx code Z91.19 (patient's non-compliance with medical regimen? ( I saw someone post on here not too long ago that this code can be used to indicate "poor prep) However, when provider go the way to the cecum, the is consider complete, therefore, when he documents "poor prep" and wants to repeat in 3 to 6 months, we have an issues with denials because of the fact that they "REACH the CECUM" has anyone else had this issue?
 
NETTECE1 said:
Hi, I hope this helps. I had scope training through NAMAS (National Alliance of Medical auditing specialists. I am AAPC and NAMAS certified. The provider would use a modifier 53 since they plan to reschedule. A 52 would be used if they didn't reschedule the procedure. In the comment section for your 45378- be sure to note poor bowel prep. It is still a complete scope but if the provider repeats and doesn't have an explanation for performing 2 in a short time frame you can get a denial for a duplicate or procedure being performed to soon. You will still use the Z code to show it was stopped.

Mooney CPC, CEMA
Click to expand...
Hello, I would love your input if on this question: Would you also use Modifier 53 when the exam is terminated at the cecum and the doctor documented poor prep and will repeat within 3 to 6 months or next available?
 
CPT assistant Aug 2021 Volume 31 Issue 8 clarifies a colonoscopy reaching the cecum that needs a repeat procedure due to poor prep would not get a 52 or 53 modifier because the complete procedure was performed if it reaches the cecum.
 
ColleenDavies said:
CPT assistant Aug 2021 Volume 31 Issue 8 clarifies a colonoscopy reaching the cecum that needs a repeat procedure due to poor prep would not get a 52 or 53 modifier because the complete procedure was performed if it reaches the cecum.
Click to expand...
There has been an update to the 2021 CPT assistant instructions. Here is a newer update. (link is at the bottom).

MLN & Colonoscopy due to Positive Cologuard
Thursday, April 4, 2024
8:34 AM
What’s the right code to use when a patient needs a screening colonoscopy following a positive result from a non-invasive CRC screening test?
For commercial and Medicaid patients who have a colonoscopy following a positive non-invasive CRC screening test, use modifier 33 with the appropriate colonoscopy code (e.g., 45378, 45380) based on the procedure(s) performed.
For Medicare beneficiaries who have a colonoscopy following a positive result for any of the following non-invasive stool-based CRC screening tests on or after 1/1/2023, use the appropriate HCPCS codes G0105 or G0121 with the KX modifier.
  • Screening guaiac-based fecal occult blood test (gFOBT) (CPT 82270)
  • Screening immunoassay-based fecal occult blood test (iFOBT) (HCPCS G0328)
  • Cologuard™ – multi-target stool DNA (sDNA) test (CPT 81528)
If modifier KX is not added to G0105 or G0121 for colonoscopy following a positive non-invasive stool-based test, Medicare will return the screening colonoscopy claim as “unprocessable.” If this happens, add modifier KX and resubmit the claim.
If polyps are removed during a screening colonoscopy for a Medicare patient, use the appropriate CPT code (45380, 45384, 45385, 45388) and add modifier PT (colorectal cancer screening test; converted to diagnostic test or other procedure) to each CPT code. However, it is important to note that if a polyp is removed during a screening colonoscopy, the Medicare beneficiary is responsible for 15% of the cost from 2023 to 2026. This falls to 10% of the cost from 2027 to 2029, and by 2030 it will be covered 100% by Medicare. Some Medicare beneficiaries are not aware that Medicare has not fully eliminated the coinsurance responsibility yet.

From <https://gastro.org/practice-resources/reimbursement/coding/coding-faq-screening-colonoscopy/>
 
Also here is info regarding use of Diagnosis in the above scenario.
Sorry I do not remember which place I found this question. Maybe from My Advisor in Vitalware.

I
 

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kat wilson said:
There has been an update to the 2021 CPT assistant instructions. Here is a newer update. (link is at the bottom).

MLN & Colonoscopy due to Positive Cologuard
Thursday, April 4, 2024
8:34 AM
What’s the right code to use when a patient needs a screening colonoscopy following a positive result from a non-invasive CRC screening test?
For commercial and Medicaid patients who have a colonoscopy following a positive non-invasive CRC screening test, use modifier 33 with the appropriate colonoscopy code (e.g., 45378, 45380) based on the procedure(s) performed.
For Medicare beneficiaries who have a colonoscopy following a positive result for any of the following non-invasive stool-based CRC screening tests on or after 1/1/2023, use the appropriate HCPCS codes G0105 or G0121 with the KX modifier.

  • Screening guaiac-based fecal occult blood test (gFOBT) (CPT 82270)

  • Screening immunoassay-based fecal occult blood test (iFOBT) (HCPCS G0328)

  • Cologuard™ – multi-target stool DNA (sDNA) test (CPT 81528)
If modifier KX is not added to G0105 or G0121 for colonoscopy following a positive non-invasive stool-based test, Medicare will return the screening colonoscopy claim as “unprocessable.” If this happens, add modifier KX and resubmit the claim.
If polyps are removed during a screening colonoscopy for a Medicare patient, use the appropriate CPT code (45380, 45384, 45385, 45388) and add modifier PT (colorectal cancer screening test; converted to diagnostic test or other procedure) to each CPT code. However, it is important to note that if a polyp is removed during a screening colonoscopy, the Medicare beneficiary is responsible for 15% of the cost from 2023 to 2026. This falls to 10% of the cost from 2027 to 2029, and by 2030 it will be covered 100% by Medicare. Some Medicare beneficiaries are not aware that Medicare has not fully eliminated the coinsurance responsibility yet.

From <https://gastro.org/practice-resources/reimbursement/coding/coding-faq-screening-colonoscopy/>
Click to expand...
This is the article I should have used...but the above info is good.
\
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.
From <https://gastro.org/practice-resources/reimbursement/coding/coding-faq-screening-colonoscopy/>
 
ColleenDavies said:
CPT assistant Aug 2021 Volume 31 Issue 8 clarifies a colonoscopy reaching the cecum that needs a repeat procedure due to poor prep would not get a 52 or 53 modifier because the complete procedure was performed if it reaches the cecum.
Click to expand...
I agree & disagree, coding makes itself so complicated. I wouldn't use a modifier 52 or 53 because he completed the procedure, however the MD wants to perform the px withing the restricted time, so appending a modifier would be the correct thing to do. Can someone clarify why modifier 53? from my understanding modifier 53 is used when the procedure was started but had to be stopped because of the patient's condition and modifier 52 is used when the procedure was completed but did not fulfill all of it requirements.
 
gastrobilling said:
I agree & disagree, coding makes itself so complicated. I wouldn't use a modifier 52 or 53 because he completed the procedure, however the MD wants to perform the px withing the restricted time, so appending a modifier would be the correct thing to do. Can someone clarify why modifier 53? from my understanding modifier 53 is used when the procedure was started but had to be stopped because of the patient's condition and modifier 52 is used when the procedure was completed but did not fulfill all of it requirements.
Click to expand...
Following
 
mvallejo0902@gmail.com said:
Following
Click to expand...
We use modifier -53 because our MAC will not accept modifier -52. Novitas JL Pennsylvania. If the scope reaches the cecum but our provider specifically states that he did not get a clear view of the colon and he documents his plan as "repeat screening with 2 day prep" I bill a screening with modifier -53.
 
bethb said:
We use modifier -53 because our MAC will not accept modifier -52. Novitas JL Pennsylvania. If the scope reaches the cecum but our provider specifically states that he did not get a clear view of the colon and he documents his plan as "repeat screening with 2 day prep" I bill a screening with modifier -53.
Click to expand...
technically the colonoscopy is not incomplete if the scope reached the cecum, but I see what you mean, where it states, "no clear view of colon" therefore the "colon cancer screening is not complete". Thank you for your reply.
 
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