Thursday 29 December 2016

Medicare Procedure Code 45378

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.”

Therefore, in accordance with the change in CPT Manual language, the Centers for Medicare and Medicaid Services (CMS) has applied specified values in the Medicare Physician Fee Schedule (MPFS) database for the following codes:

 44388-53 (colonoscopy through stoma);

 45378-53 (colonoscopy);

 G0105-53 (colorectal cancer screening; colonoscopy on individual at high risk; and

 G0121-53 (colorectal cancer screening; colonoscopy on individual not meeting criteria for high 
risk).

Effective for services performed on or after January 1, 2016, the MPFS database will have specific values for the codes listed above. 

Given that the new CPT definition of an incomplete colonoscopy also include colonoscopies where the colonoscope is advanced past the splenic flexure but not to the cecum, CMS has established new values for incomplete diagnostic and screening colonoscopies performed on or after January 1, 2016. 

Incomplete colonoscopies are reported with Modifier 53. Medicare will pay for the interrupted colonoscopy at a rate that is calculated using one-half the value of the inputs for the codes.

CLAIMS REVIEW AND ADJUDICATION PROCEDURES 

Codes G0105 and G0121 (colorectal cancer screening colonoscopies) must be paid at rates consistent with payment for similar or related services under the physician fee schedule, not to exceed the rates for a diagnostic colonoscopy (CPT code 45378). (The same RVUs have been assigned to codes G0105 and G0121 as those assigned to CPT code 45378.)

If during the course of the screening colonoscopy, a lesion or growth is detected which results in a  biopsy or removal of the growth, the appropriate procedure classified as a colonoscopy with biopsy or removal must be billed and paid rather than code G0105 or G0121.

Remittance Advice Notices.—

Ambulatory Surgical Center Facility Fee.--CPT code 45378, which is used to code a diagnostic colonoscopy, is on the list of procedures approved by Medicare for payment of an ambulatory surgical center (ASC) facility fee under §1833(I) of the Act. 

CPT code 45378 is currently assigned to ASC payment group 2. Code G0105 (colorectal cancer screening; colonoscopy on individual at high risk) has been added to the ASC list effective for services furnished on or after January 1, 1998.

Code G0121 (colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk) was added to the ASC list effective for services furnished on or after July 1, 2001. Codes G0105 and G0121 are assigned to ASC payment group 2. The ASC facility service is the same whether the procedure is a screening or a diagnostic colonoscopy.

The BCBSMA Policy is predicated on the reason the colonoscopy visit was scheduled. If the visit was scheduled as routine and a finding was discovered during the procedure, the visit is considered routine. Please see the sample billing guidelines below:

If the service is a:  Screening colonoscopy for a low risk patient with no findings during the colonoscopy

Then the gastroenterologist should submit the claim using:

Procedure Diagnosis

The colonoscopy procedure code:

o 45378 with modifier 33 indicating that the service was preventive 

OR 

o G0121

If the service is a:  Diagnostic colonoscopy performed due to signs or symptoms, or to ruleout or confirm a suspected diagnosis

Procedure Diagnosis

The colonoscopy procedure code:

o 45378 WITHOUT modifier 33

o DO NOT use the G screening codes listed above

cpt 45378

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

COLONOSCOPY

CPT CODES: 

44388 Colonoscopy through stoma: diagnostic, with or without collection of specimen(s) by brushing or washing

44389 with biopsy, single or multiple

44390 with removal of foreign body

44391 with control of bleeding, any method

44392 with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery

44394 with removal of tumor(s), polyp(s), or other lesion(s) by snare technique

45355 Colonoscopy, rigid or flexible, transabdominal via colotomy, single or multiple

45378 Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen(s) by brushing or washing, with or without colon decompression

45379 with removal of foreign body

45380 with biopsy, single or multiple

45382 with control of bleeding, any method

45383 with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy  forceps, bipolar cautery or snare technique

45384 with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery

45385 with removal of tumor(s), polyp(s), or other lesion(s) by  snare technique

New Values for Incomplete Colonoscopies Billed with Modifier 53 

Provider Types Affected

This MLN Matters® Article is intended for providers submitting claims to Medicare Administrative Contractors (MACs) for services to Medicare beneficiaries related to incomplete colonoscopies billed with Modifier 53.

Provider Action Needed

STOP – Impact to You

Change Request (CR) 9317, from which this article is taken, revises the method for calculating payment for discontinued procedures. New payment rates will apply when Modifier 53 (discontinued procedure) is appended to codes 44388, 45378, G0105, and G0121.

CAUTION – What You Need to Know

Effective for services performed on or after January 1, 2016, the Medicare Physician Fee Schedule (MPFS) database will have specific values for Current Procedural Terminology (CPT) codes 44388-53; 45378-53; G0105-53; and G0121-53.

GO – What You Need to Do 

Make sure that your billing staffs are aware of these revisions for calculating payments for discontinued procedures using Modifier 53. Incomplete colonoscopies are reported with Modifier 53. Medicare will pay for the interrupted colonoscopy at a rate that is calculated using one-half the value of the inputs for the codes.

Background

According to CPT instruction, prior to calendar year (CY) 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 and append Modifier 53 (discontinued procedure), 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. 

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