Remember back in 2015 when CPT® changed the definition of an incomplete colonoscopy from one that does not evaluate the colon past the splenic flexure to one that does not evaluate the entire colon? The Centers for Medicare & Medicaid Services (CMS) is responding to that change, albeit rather lethargically.

CPT® 2015 stated (and continues to state):

Colonoscopy is the examination of the entire colon, from the rectum to the cecum, and may include the examination of the terminal ileum or small intestine proximal to an anastomosis. … if the physician is unable to advance the colonoscope to the cecum or colon-small intestine anastomosis due to unforeseen circumstances, report 45378 or 44388 with modifier 53 and provide appropriate documentation.

Three years later, CMS has established new values in the Medicare Physician Fee Schedule (MPFS) database for incomplete diagnostic and screening colonoscopies performed in critical access hospitals (CAHs) on or after Jan. 1, 2016. Medicare will pay for an interrupted colonoscopy at a rate that is calculated using one-half the value of the inputs for the following codes when reported with modifier 53 Discontinued procedure:

44388 Colonoscopy through stoma; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)

45378 Colonoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)

G0105 Colorectal cancer screening, colonoscopy on individual at high risk

G0121 Colorectal cancer screening, colonoscopy on individual not meeting criteria for high risk

Physicians were previously instructed to report an incomplete colonoscopy (defined as a colonoscopy that did not evaluate the colon past the splenic flexure) with 45378-53 and were paid at the same rate as a sigmoidoscopy. Effective for services performed on or after April 1, 2019, the MPFS database will have “specific” values for these codes, according to MLN Matters MM10937.

This payment methodology for CAH Method II providers is consistent with what is in the Medicare Claims Processing Manual Pub. 100-04, chapter 12, section 30.1 and chapter 18, section 60.2. The value change applies to CAH providers submitting claims to Medicare on Type of Bill 85X.

Related Reading on the Knowledge Center

Coding for “Incomplete” Colonoscopy

Modifiers and Incomplete Colonoscopy

Medicare Screening Colonoscopy Coverage