2015-11-30 14:23:49 UTC

Updated Payments for Incomplete Colonoscopies

Nov. 30, 2015

Make sure to alert your billing staff to these revisions for calculating payments.

CMS is increasing payments for incomplete colonoscopies. Beginning Jan. 1, 2016, Medicare will pay for an incomplete colonoscopy reported with the 53 modifier (Discontinued Procedure) at “one half the value of the value of the inputs for these codes,” according to MLN Matters.

The payments were increased in response to a change in the definition of colonoscopy in the 2015 CPT manual. Prior to 2015, an incomplete colonoscopy was defined as a colonoscopy that did not evaluate the colon past the splenic flexure (the distal third of the colon). Physicians were previously instructed to report an incomplete colonoscopy with 45378 with modifier 53, which is paid at the same rate as a sigmoidoscopy.

In CY 2015, the CPT instruction changed the definition of an incomplete colonoscopy to a colonoscopy that does not evaluate the entire colon. The 2015 CPT Manual states: 

“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.” 

CMS has assigned the following rates to these incomplete colonoscopy procedures:

CPT Mod Short Descriptor 2016 Facility Total RVU 2016 Facility Payment 2016 Non-Facility Total  2016 Non-Facility Payment
44388 53 C-stoma 2.34 $83.84 4.98 $178.42
45378 53 Diagnostic colonoscopy 2.79 $99.96 5.38 $192.75
G0105 53 Colorectal scrn; hi risk ind 2.8 $100.32 5.37 $192.40
G0121 53 Colon ca scrn; not hi risk ind 2.8 $100.32 5.37 $192.40

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