Incomplete colonoscopy billing requirements
CMS established values for incomplete diagnostic and screening colonoscopies under CPT definition of an incomplete colonoscopy where the colonoscope is advanced past the splenic flexure, but not to the cecum.
Medicare will pay for the interrupted colonoscopy at a rate that is calculated using one-half the value of the inputs for the codes listed:
- 44388-53 (colonoscopy through stoma)
- 45378-53 (colonoscopy)
- G0105-53 (colorectal cancer screening; colonoscopy on individual at high risk)
- G0121-53 (colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk)
Please be aware of the correct coding guidelines when billing an incomplete colonoscopy if you are reporting CPT 45380 (Colonoscopy, with biopsy, single or multiple) when a more appropriate CPT code is available. Coding correctly the first time will eliminate the need to appeal the claim.
In some cases, you may plan to provide a colonoscopy (screening or diagnostic) but, due to unforeseen circumstances, may be unable to complete the procedure. If you prep the patient for a screening or diagnostic colonoscopy and do not advance the scope due to obstruction, patient discomfort, or other complications; append modifier 53 (discontinued procedure) to report an incomplete colonoscopy.
In the claim narrative, indicate the reason why the colonoscopy was not completed as well as how far the scope was able to be advanced (e.g. the colonoscope was advanced to the sigmoid colon and terminated due to inadequate prep.).
Note: When a covered colonoscopy is next attempted and completed, Medicare will pay according to the payment methodology for this procedure as long as coverage conditions are met. This policy is applied to both screening and diagnostic colonoscopies.
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