Covered colonoscopy is attempted but cannot be completed due to extenuating circumstances

December 21st, 2016 - Chris Woolstenhulme, QCC, CMCS, CPC, CMRS
Categories:   Modifiers   Reimbursement   Claims   HCPCS Coding  
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Medicare will pay for the interrupted colonoscopy as long as the coverage conditions are met for the incomplete procedure. However, the frequency standards associated with screening colonoscopies will not be applied by CWF. 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, and the frequency standards will be applied by CWF. This policy is applied to both screening and diagnostic colonoscopies.

When submitting a facility claim for the interrupted colonoscopy, providers are to suffix the colonoscopy HCPCS codes with a modifier of “–73” or” –74” as appropriate to indicate that the procedure was interrupted. Payment for covered incomplete screening colonoscopies shall be consistent with payment methodologies currently in place for complete screening colonoscopies, including those contained in 42 CFR 419.44(b). In situations where a critical access hospital (CAH) has elected payment Method II for CAH patients, payment shall be consistent with payment methodologies currently in place … As such, CAHs that elect Method II payment [should] use modifier “–53” to identify an incomplete screening colonoscopy (physician professional service(s) billed in revenue code 096X, 097X, and/or 098X). Such CAHs will also bill the technical or facility component of the interrupted colonoscopy in revenue code 075X (or other appropriate revenue code) using the “-73” or “-74” modifier as appropriate.

Note that Medicare would expect the provider to maintain adequate information in the patient’s medical record in case it is needed by the contractor to document the incomplete procedure.

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