Health Information Management

Incomplete colonoscopy coding

APCs Insider, June 10, 2004

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QUESTION: Our facility had a Medicare patient come in for a colonoscopy because of family history of colon cancer. The endoscopy was not completed because the physician was unable to advance the scope to the distal sigmoid colon. We assigned a CPT code (45330) to the extent of the procedure (flexible sigmoidoscopy) performed.

Our billing office has indicated that according to Medicare guidelines that the code assignment should be an incomplete or interrupted colonoscopy with the modifier-74 or G0105-74. Can you give us some clarification on which is the correct way?

ANSWER: It is important the outpatient coding staff read and implement coding policy according to Program Memorandum (PM) AB-03-114, "Claims Processing and Payment of Incomplete Screening Colonoscopies," implemented January 1, 2004. Visit www.cms.hhs.gov to view the PM.

Medicare covers colorectal cancer screening tests/procedures for the early detection of colorectal cancer when coverage conditions are met using the following codes:

  • G0105-Colorectal cancer screening; colonoscopy on individual at high risk, subject to a frequency limitation of two years.
  • G0121-Colorectal screening; colonoscopy on individual not meeting criteria for high risk, subject to a frequency limitation of 10 years.

When a covered screening colonoscopy is attempted but cannot be completed due to extenuating circumstances, Medicare will pay for the interrupted colonoscopy as long as the coverage conditions are met for the incomplete procedure.

Due to the Common Working File (CWF) ability to apply the frequency standards with the above two codes, providers should suffix the colonoscopy HCPCS codes with a modifier -73 (discontinued outpatient procedure prior to anesthesia administration) or -74 (discontinued outpatient procedure after anesthesia administration) as appropriate to indicate that the procedure is interrupted. Payment for the covered incomplete screening colonoscopies shall be consistent with payment methodologies currently in place for complete screening colonoscopies including those contained in 42 CFR 419.44(b).

Tip: Modifiers -73 and -74 are reported in conjunction with discontinued procedures before and after the administration of local, general, or regional anesthesia; however, Medicare makes an exception with interrupted screening colonoscopies G0105 and G0121, which are typically performed under intravenous conscious sedation.



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