Medicare Changes Payment for Incomplete Colonoscopies

Effective for services performed on or after Jan. 1, 2016, the Medicare Physician Fee Schedule has specific values for these Current Procedural Terminology (CPT) colonoscopy codes when billed with modifier 53 (discontinued procedure): 

  • 44388 (colonoscopy through stoma);
  • 45378 (colonoscopy); 
  • G0105 (colorectal cancer screening; colonoscopy on individual at high risk); and 
  • G0121 (colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk).  

Medicare says it will pay for the interrupted colonoscopy “at a rate that is calculated using one-half the value of the inputs for the codes.”

Medicare made this change to conform with the definition of an incomplete colonoscopy that CPT adopted in 2015: “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.”

Previously, CPT defined an incomplete colonoscopy as one that did not evaluate the colon past the splenic flexure (the distal third of the colon). For incomplete colonoscopies performed before Jan. 1, 2016, physicians reported an incomplete colonoscopy with CPT code 45378 and modifier 53, and were paid at the same rate as a sigmoidoscopy. CMS established the new values for incomplete diagnostic and screening colonoscopies performed after Jan. 1, 2016, “given that the new CPT definition of an incomplete colonoscopy also include[s] colonoscopies where the colonoscope is advanced past the splenic flexure but not to the cecum.” 

The Centers for Medicare & Medicaid Services (CMS) has revised Chapter 12, Section 30.1, and Chapter 18, Section 60.2 of the Medicare Claims Processing Manual to reflect this information. See also: CMS’ MLN Matters No. MM9317.

If you have questions about billing and coding, contact the specialists at paymentadvocacy[at]texmed[dot]org for help, or call the TMA Knowledge Center at (800) 880-7955.

Published Jan. 13, 2016

Last Updated On

May 13, 2016