Article - Billing and Coding: Diagnostic and Therapeutic Colonoscopy (A57343)

CMS National Coverage PolicyTitle XVIII of the Social Security Act (SSA), 1862(a)(1)(A) states that no Medicare payment shall be made for items or services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.Title XVIII of the Social Security Act, 1862(a)(7) and 42 Code of Federal Regulations, 411.15 et seq. exclude routine physical examinations.Title XVIII of the Social Security Act, 1833(e) prohibits Medicare payment for any claim lacking the necessary documentation to process the claim.Title XVIII of the Social Security Act, 1862(a)(1)(H) and Balanced Budget Act 97, Chapter V, Subtitle B, 4104 provides coverage for colorectal cancer screening tests.CMS Manual System, Publication 100-04,Medicare Claims Processing Manual,Chapter 12, 30.1B, addresses incomplete colonoscopies.Article TextThe following billing and coding guidance is to be used with its associated Local Coverage Determination.Coding GuidelinesDo not report a colonoscopy procedure code for an endoscopy performed with a sigmoidoscope on a patient with a normal length colon, even if the sigmoidoscope reaches proximal to the splenic flexure. A sigmoidoscope (an endoscope typically 65 centimeters in length) may be used for a colonoscopy only if the bowel is sufficiently short so that the entire colon may be examined, and such should be clearly documented in the clinical record.Payment for a colonoscopy performed in the office is subject to recovery when colonoscope information is not available to the contractor.An incomplete colonoscopy is defined by CMS in the IOM at 100-4, Chapter 12, Section 30.1.B;Incomplete Colonoscopies (Codes 44388, 45378, G0105 and G0121).An incomplete colonoscopy, e.g., the inability to advance the colonoscope to the cecum or colon-small intestine anastomosis due to unforeseen circumstances, is billed and paid using colonoscopy through stoma code 44388, colonoscopy code 45378, and screening colonoscopy codes G0105 and G0121 with modifier -53. (Code 44388 is valid with modifier 53 beginning January 1, 2016.) The Medicare physician fee schedule database has specific values for codes 44388-53, 45378-53, G0105-53 and G0121-53. An incomplete colonoscopy performed prior to January 1, 2016, is paid at the same rate as a sigmoidoscopy. Beginning January 1, 2016, Medicare will pay for the interrupted colonoscopy at a rate that is calculated using one-half the value of the inputs for the codes.When the colonoscopy procedure is unusual or difficult, modifier 22 (unusual procedural services) may be reported.The most specific ICD-10-CM code must be chosen and billed to its highest level of specificity. Submit this as the line diagnosis (linked to the procedure) on the claim.LimitationsThe requirements for coverage havenotbeen met if:Only a sigmoidoscope is used.An office-based colonoscopy is not validated with the appropriate equipment information.Chronic abdominal pain unresponsive to medical therapy is used to justify the service but lacks appropriate clinical documentation.Documentation RequirementSupportive clinical documentation evidencing the condition and treatment is expected to be documented in the clinical notes or procedure note and be made available upon request from the MAC or other authorized CMS auditor.Medical records need not be submitted with the claim unless modifier 22 is used; however, they must be furnished to Medicare upon request.The medical records must support the medical reasonableness, necessity, and frequency of each diagnostic service supplied.The medical record must substantiate the diagnosis listed on the claim form.The colonoscopy report must describe the following:The maximum depth of penetration;A description of any abnormal findings; andAny procedures performed as the result of such findings (e.g., biopsy).