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Failed Colonoscopy: Screening & Diagnostic
Screening Colonoscopy
Medicare covers colorectal cancer screening tests and procedures for the early detection of colorectal cancer when coverage conditions are met. Coverage of these procedures is subject to certain frequency limitations. Among the screening procedures covered are screening colonoscopies, which are submitted to Medicare with the following HCPCS codes:
- G0105: colorectal cancer screening; colonoscopy on individual at high risk
- G0121: colorectal screening; colonoscopy on individual not meeting criteria for high risk
Diagnostic Colonoscopy
Medicare may also cover a diagnostic colonoscopy when the procedure is medically necessary. The Palmetto GBA Local Coverage Determination (LCD) for Diagnostic Lower Gastrointestinal Endoscopy was retired, effective October 1, 2005. Because there is no LCD in place for these services to establish a specific definition of 'medical necessity,' the definition of medical necessity for these services is based upon section 1862 (a)(1)(A) of the Social Security Act (the Act). The Act defines medically necessary services as those which are: 'reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.'
The fact that the colonoscopy is being performed based on signs and/or symptoms exhibited by the patient is what defines the procedure as a diagnostic colonoscopy. Screening colonoscopies are performed in the absence of signs or symptoms.
Failed Colonoscopy
When a covered colonoscopy is attempted but cannot be completed because of extenuating circumstances (e.g., the inability to extend beyond the splenic flexure), Medicare will pay for the interrupted colonoscopy at a rate consistent with that of a flexible sigmoidoscopy as long as coverage conditions are met for the incomplete procedure. When a covered colonoscopy is next attempted and completed, Medicare will pay for that colonoscopy according to its payment methodology for this procedure, as long as coverage conditions are met. This policy is applied to both screening and diagnostic colonoscopies.
Claim Submission
- Professional providers (i.e., physicians or providers who perform the colonoscopy):
- For an incomplete screening colonoscopy, submit the appropriate HCPCS code (based on the patient's identified risk) with CPT modifier 53. The incomplete screening colonoscopy will not be considered by Medicare in determining the allowed frequency.
- For an incomplete diagnostic colonoscopy, submit CPT code 45378 with CPT modifier 53
- Ambulatory Surgical Centers (facility charges): submit the appropriate colonoscopy code with CPT modifier 73 or CPT modifier 74, as appropriate
- In all instances, it is important to maintain adequate information in the patient's medical record in case it is needed to document the incomplete procedure
Reference
- CMS Web site
- CMS Publication 100-04, Medicare Claims Processing Manual, Ch. 12, section 30.1
- CMS Publication 100-02, Medicare Benefit Policy Manual, Ch.15, section 280.2