Medical Billing and Coding Healthcare Blog

The Centers for Medicare & Medicaid Services (CMS) has announced it is revising the method for calculating payment for incomplete colonoscopies billed with modifier -53.

Effective January 1, 2016, the new payment rates will apply when modifier -53 (discontinued procedure) is appended to Current Procedural Terminology (CPT) codes 44388, 45378, G0105 and G0121.

As CMS notes, prior to calendar year (CY) 2015, according to CPT instruction, 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.

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."

Given that the new CPT definition of an incomplete colonoscopy also includes 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 the -53 modifier. Medicare will pay for the interrupted colonoscopy at a rate that is calculated using one-half the value of the inputs for the codes: 44388-53, 45378-53, G0105-53 and G0121-53.

According to an American Gastroenterological Association report, CMS has assigned the following 2016 facility payment rates to these incomplete colonoscopy procedures with modifier -53 (includes partial CPT code descriptions):

  • C-stoma (CPT code 44388): $83.84
  • Diagnostic colonoscopy (CPT code 45378): $99.96
  • Colorectal cancer screen, high risk (CPT code G0105): $100.32
  • Colorectal cancer screen, not high risk (CPT code G0121): $100.32

The 2016 non-facility payment rates for these incomplete colonoscopy procedures with modifier -53 are as follows:

  • C-stoma: $178.42
  • Diagnostic colonoscopy: $192.75
  • Colorectal cancer screen, high risk: $192.40
  • Colorectal cancer screen, not high risk: $192.40

Make sure your billing staff is aware of these revisions for calculating payments for discontinued procedures using modifier -53.

Is your practice struggling with accurate medical billing and coding for gastroenterology? Contact PGM Billing, a leading provider of physician billing services. PGM has extensive experience with both gastroenterology and endoscopy billing, and can manage all aspects of your practice's billing.

The Centers for Medicare & Medicaid Services (CMS) has posted its final Level II HCPCS application determinations for 2016.

Level II of the HCPCS is a standardized coding system that is used primarily to identify products, supplies and services not included in the CPT-4 codes, such as ambulance services and durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) when used outside a physician's office.

Since Medicare and other insurers cover a variety of services, supplies, and equipment that are not identified by CPT-4 codes, the level II HCPCS codes were established for submitting claims for these items.

Here is the list of HCPCS codes undergoing a change for 2016. Changes include additions, changes in long description, discontinuations, changes in coverage and payment changes. Note: If you need assistance finding a particular HCPCS code, use PGM Billing's HCPCS Lookup Tool. The HCPCS Codes Lookup Tool provides users with the ability to perform HCPCS code searches to obtain the correct code and description.

 

HCPCS/Modifier Code Type of Change
CP Add
CT Add
EX Add
ZA Add
A4337 Add
C1822 Add
C2613 Add
C2623 Add
C2645 Add
C9458 Add
C9459 Add
C9460 Add
C9743 Add
E0465 Add
E0466 Add
E1012 Add
G0296 Add
G0297 Add
G0298 Add
G0299 Add
G0300 Add
G0475 Add
G0476 Add
G9473 Add
G9474 Add
G9475 Add
G9476 Add
G9477 Add
G9478 Add
G9479 Add
G9480 Add
G9496 Add
G9497 Add
G9498 Add
G9499 Add
G9500 Add
G9501 Add
G9502 Add
G9503 Add
G9504 Add
G9505 Add
G9506 Add
G9507 Add
G9508 Add
G9509 Add
G9510 Add
G9511 Add
G9512 Add
G9513 Add
G9514 Add
G9515 Add
G9516 Add
G9517 Add
G9518 Add
G9519 Add
G9520 Add
G9521 Add
G9522 Add
G9523 Add
G9524 Add
G9525 Add
G9526 Add
G9529 Add
G9530 Add
G9531 Add
G9532 Add
G9533 Add
G9534 Add
G9535 Add
G9536 Add
G9537 Add
G9538 Add
G9539 Add
G9540 Add
G9541 Add
G9542 Add
G9543 Add
G9544 Add
G9547 Add
G9548 Add
G9549 Add
G9550 Add
G9551 Add
G9552 Add
G9553 Add
G9554 Add
G9555 Add
G9556 Add
G9557 Add
G9558 Add
G9559 Add
G9560 Add
G9561 Add
G9562 Add
G9563 Add
G9572 Add
G9573 Add
G9574 Add
G9577 Add
G9578 Add
G9579 Add
G9580 Add
G9581 Add
G9582 Add
G9583 Add
G9584 Add
G9585 Add
G9593 Add
G9594 Add
G9595 Add
G9596 Add
G9597 Add
G9598 Add
G9599 Add
G9600 Add
G9601 Add
G9602 Add
G9603 Add
G9604 Add
G9605 Add
G9606 Add
G9607 Add
G9608 Add
G9609 Add
G9610 Add
G9611 Add
G9612 Add
G9613 Add
G9614 Add
G9615 Add
G9616 Add
G9617 Add
G9618 Add
G9619 Add
G9620 Add
G9621 Add
G9622 Add
G9623 Add
G9624 Add
G9625 Add
G9626 Add
G9627 Add
G9628 Add
G9629 Add
G9630 Add
G9631 Add
G9632 Add
G9633 Add
G9634 Add
G9635 Add
G9636 Add
G9637 Add
G9638 Add
G9639 Add
G9640 Add
G9641 Add
G9642 Add
G9643 Add
G9644 Add
G9645 Add
G9646 Add
G9647 Add
G9648 Add
G9649 Add
G9650 Add
G9651 Add
G9652 Add
G9653 Add
G9654 Add
G9655 Add
G9656 Add
G9657 Add
G9658 Add
G9659 Add
G9660 Add
G9661 Add
G9662 Add
G9663 Add
G9664 Add
G9665 Add
G9666 Add
G9667 Add
G9668 Add
G9669 Add
G9670 Add
G9671 Add
G9672 Add
G9673 Add
G9674 Add
G9675 Add
G9676 Add
G9677 Add
J0202 Add
J0596 Add
J0695 Add
J0714 Add
J0875 Add
J1443 Add
J1447 Add
J1575 Add
J1833 Add
J2407 Add
J2502 Add
J2547 Add
J2860 Add
J3090 Add
J3380 Add
J7121 Add
J7188 Add
J7205 Add
J7297 Add
J7298 Add
J7313 Add
J7328 Add
J7340 Add
J7503 Add
J7512 Add
J7999 Add
J8655 Add
J9032 Add
J9039 Add
J9271 Add
J9299 Add
J9308 Add
L8607 Add
P9070 Add
P9071 Add
P9072 Add
Q4161 Add
Q4162 Add
Q4163 Add
Q4164 Add
Q4165 Add
Q5101 Add
Q9950 Add
Q9980 Add
B5000 Change in Long Description
B5100 Change in Long Description
B5200 Change in Long Description
C1820 Change in Long Description
C9349 Change in Long Description
G8399 Change in Long Description
G8400 Change in Long Description
G8401 Change in Long Description
G8458 Change in Long Description
G8465 Change in Long Description
G8784 Change in Long Description
G8924 Change in Long Description
G8925 Change in Long Description
G8928 Change in Long Description
G8929 Change in Long Description
G8955 Change in Long Description
G9196 Change in Long Description
G9226 Change in Long Description
G9277 Change in Long Description
G9286 Change in Long Description
G9287 Change in Long Description
G9298 Change in Long Description
G9354 Change in Long Description
G9384 Change in Long Description
G9385 Change in Long Description
G9389 Change in Long Description
G9390 Change in Long Description
G9419 Change in Long Description
G9429 Change in Long Description
G9460 Change in Long Description
G9467 Change in Long Description
J0571 Change in Long Description
J0572 Change in Long Description
J0573 Change in Long Description
J0574 Change in Long Description
J0575 Change in Long Description
J1442 Change in Long Description
J7508 Change in Long Description
K0017 Change in Long Description
K0018 Change in Long Description
L1902 Change in Long Description
L1904 Change in Long Description
L8621 Change in Long Description
Q4153 Change in Long Description
JF Discontinued
A7011 Discontinued
C9025 Discontinued
C9026 Discontinued
C9027 Discontinued
C9136 Discontinued
C9442 Discontinued
C9443 Discontinued
C9444 Discontinued
C9445 Discontinued
C9446 Discontinued
C9448 Discontinued
C9449 Discontinued
C9450 Discontinued
C9451 Discontinued
C9452 Discontinued
C9453 Discontinued
C9454 Discontinued
C9455 Discontinued
C9456 Discontinued
C9457 Discontinued
C9724 Discontinued
C9737 Discontinued
E0450 Discontinued
E0460 Discontinued
E0461 Discontinued
E0463 Discontinued
E0464 Discontinued
G0154 Discontinued
G0431 Discontinued
G0434 Discontinued
G6018 Discontinued
G6019 Discontinued
G6020 Discontinued
G6021 Discontinued
G6022 Discontinued
G6023 Discontinued
G6024 Discontinued
G6025 Discontinued
G6027 Discontinued
G6028 Discontinued
G8530 Discontinued
G8531 Discontinued
G8532 Discontinued
G8713 Discontinued
G8714 Discontinued
G8717 Discontinued
G8718 Discontinued
G8720 Discontinued
G8870 Discontinued
G8871 Discontinued
G8951 Discontinued
G9320 Discontinued
G9323 Discontinued
G9325 Discontinued
G9328 Discontinued
G9343 Discontinued
G9346 Discontinued
G9362 Discontinued
G9363 Discontinued
G9369 Discontinued
G9370 Discontinued
G9376 Discontinued
G9377 Discontinued
G9378 Discontinued
G9379 Discontinued
G9391 Discontinued
G9392 Discontinued
G9433 Discontinued
J0886 Discontinued
J1446 Discontinued
J7302 Discontinued
J7506 Discontinued
J9010 Discontinued
Q9975 Discontinued
Q9976 Discontinued
Q9977 Discontinued
Q9978 Discontinued
Q9979 Discontinued
S0195 Discontinued
S2360 Discontinued
S2361 Discontinued
S3721 Discontinued
S3854 Discontinued
S3890 Discontinued
S5011 Discontinued
S8262 Discontinued
S9015 Discontinued
L7900 Change in Coverage
L7902 Change in Coverage
A4233 Change in Payment
A4234 Change in Payment
A4235 Change in Payment
A4236 Change in Payment
A9520 Change in Payment
J0200 Change in Payment
J0561 Change in Payment
J0712 Change in Payment
J0720 Change in Payment
J1364 Change in Payment
J1600 Change in Payment
J2248 Change in Payment
J2515 Change in Payment
J2730 Change in Payment
J2791 Change in Payment
J3350 Change in Payment
J3485 Change in Payment
J7180 Change in Payment
J7315 Change in Payment
J8520 Change in Payment
J8521 Change in Payment
J9020 Change in Payment
J9185 Change in Payment
J9219 Change in Payment
J9351 Change in Payment
K0899 Change in Payment
Q4122 Change in Payment
Q4127 Change in Payment
B4088 Miscellaneous Change (BETOS or Type of Service
X