Local Coverage Article Billing and Coding

Billing and Coding: Incomplete Colonoscopy/Failed Colonoscopy

A55227

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Contractor Information

Article Information

General Information

Article ID
A55227
Article Title
Billing and Coding: Incomplete Colonoscopy/Failed Colonoscopy
Article Type
Billing and Coding
Original Effective Date
07/28/2016
Revision Effective Date
06/30/2021
Revision Ending Date
N/A
Retirement Date
N/A
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CMS National Coverage Policy

Title XVIII of the Social Security Act §1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim

CMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 12, §30.1B Digestive System - Incomplete Colonoscopies (Codes 44388, 45378, G0105 and G0121)

Article Guidance

Article Text

A covered colonoscopy that is attempted but cannot be completed because of extenuating circumstances is considered to be an incomplete colonoscopy (the inability to advance the colonoscope to the cecum or to the colon-small intestine anastomosis due to unforeseen circumstances). The failed procedure is billed and paid using CPT® code 45378, HCPCS code G0105 or G0121, or CPT® code 44388, if attempting to perform the colonoscopy through an existing stoma. Modifier “-53” (discontinued procedure) must be appended to any procedure code submitted when billing for a failed colonoscopy attempt.

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 all coverage conditions are met. This applies to both screening and diagnostic colonoscopies.

Coding Information

CPT/HCPCS Codes

Group 1

(4 Codes)
Group 1 Paragraph

N/A

Group 1 Codes
CodeDescription
44388 COLONOSCOPY THROUGH STOMA; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)
45378 COLONOSCOPY, FLEXIBLE; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)
G0105 COLORECTAL CANCER SCREENING; COLONOSCOPY ON INDIVIDUAL AT HIGH RISK
G0121 COLORECTAL CANCER SCREENING; COLONOSCOPY ON INDIVIDUAL NOT MEETING CRITERIA FOR HIGH RISK

CPT/HCPCS Modifiers

Group 1

(1 Code)
Group 1 Paragraph

N/A

Group 1 Codes
CodeDescription
53 DISCONTINUED PROCEDURE: UNDER CERTAIN CIRCUMSTANCES, THE PHYSICIAN MAY ELECT TO TERMINATE A SURGICAL OR DIAGNOSTIC PROCEDURE. DUE TO EXTENUATING CIRCUMSTANCES OR THOSE THAT THREATEN THE WELL BEING OF THE PATIENT, IT MAY BE NECESSARY TO INDICATE THAT A SURGICAL OR DIAGNOSTIC PROCEDURE WAS STARTED BUT DISCONTINUED. THIS CIRCUMSTANCE MAY BE REPORTED BY ADDING THE MODIFIER -53 TO THE CODE REPORTED BY THE PHYSICIAN FOR THE DISCONTINUED PROCEDURE OR BY USE OF THE SEPARATE FIVE DIGIT MODIFIER CODE 09953. NOTE: THIS MODIFIER IS NOT USED TO REPORT THE ELECTIVE CANCELLATION OF A PROCEDURE PRIOR TO THE PATIENT'S ANESTHESIA INDUCTION AND/OR SURGICAL PREPARATION IN THE OPERATING SUITE. FOR OUTPATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) REPORTING OF A PREVIOUSLY SCHEDULED PROCEDURE/SERVICE THAT IS PARTIALLY REDUCED OR CANCELLED AS A RESULT OF EXTENUATING CIRCUMSTANCES OR THOSE THAT THREATEN THE WELL BEING OF THE PATIENT PRIOR TO OR AFTER ADMINISTRATION OF ANESTHESIA, SEE MODIFIERS -73 AND -74 (SEE MODIFIERS APPROVED FOR ASC HOSPITAL OUTPATIENT USE).

ICD-10-CM Codes that Support Medical Necessity

Group 1

(2 Codes)
Group 1 Paragraph

N/A

Group 1 Codes
CodeDescription
Z12.11 Encounter for screening for malignant neoplasm of colon
Z80.0 Family history of malignant neoplasm of digestive organs

ICD-10-CM Codes that DO NOT Support Medical Necessity

N/A

ICD-10-PCS Codes

N/A

Additional ICD-10 Information

N/A

Bill Type Codes

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

N/A

Revenue Codes

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes.

N/A

Other Coding Information

N/A

Revision History Information

Revision History DateRevision History NumberRevision History Explanation
06/30/2021 R7

Under ICD-10-CM Codes that Support Medical Necessity Group 1: Codes added Z12.11 and Z80.0. This revision is retroactive effective for dates of service on or after 6/30/21.

03/25/2021 R6

Under CMS National Coverage Policy updated section heading for regulation CMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 12, §30.1B Digestive System - Incomplete Colonoscopies (Codes 44388, 45378, G0105 and G0121).

10/10/2019 R5

This article is being revised in order to adhere to CMS requirements per chapter 13, section 13.5.1 of the Program Integrity Manual. Regulations regarding billing and coding were removed from the CMS National Coverage Policy section of the related Colonoscopy/Sigmoidoscopy/Proctosigmoidoscopy L34454 LCD and placed in this article. Under Article Title changed the title from “Incomplete Colonoscopy/Failed Colonoscopy” to “Billing and Coding: Incomplete Colonoscopy/Failed Colonoscopy”. Under CPT/HCPCS Modifiers Group 1: Codes added modifier 53. Punctuation and typographical errors were corrected throughout the article.

04/01/2019 R4

Under Article Text and CPT/HCPCS Codes Group 1: Codes added HCPCS code G0121 due to Change Request 10937, Transmittal 4153 dated October 26, 2018.

02/26/2018 R3 The Jurisdiction "J" Part B Contracts for Alabama (10112), Georgia (10212) and Tennessee (10312) are now being serviced by Palmetto GBA. The notice period for this article begins on 12/14/17 and ends on 02/25/18. Effective 02/26/18, these three contract numbers are being added to this article. No coverage, coding or other substantive changes (beyond the addition of the 3 Part B contract numbers) have been completed in this revision.
01/29/2018 R2 The Jurisdiction "J" Part A Contracts for Alabama (10111), Georgia (10211) and Tennessee (10311) are now being serviced by Palmetto GBA. The notice period for this article begins on 12/14/17 and ends on 01/28/18. Effective 01/29/18, these three contract numbers are being added to this article. No coverage, coding or other substantive changes (beyond the addition of the 3 Part A contract numbers) have been completed in this revision.
07/21/2017 R1

Annual validation with no revisions made.

Associated Documents

Related Local Coverage Documents
LCDs
L34454 - Colonoscopy/Sigmoidoscopy/Proctosigmoidoscopy
Related National Coverage Documents
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Statutory Requirements URLs
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Rules and Regulations URLs
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CMS Manual Explanations URLs
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Other URLs
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Public Versions
Updated On Effective Dates Status
06/23/2022 06/30/2021 - N/A Currently in Effect You are here
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

  • Colonoscopy
  • Screening Colonoscopy
  • Diagnostic Colonoscopy