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.
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