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Incomplete Colonoscopy

Thomas Posted Tue 16th of August, 2016 16:31:11 PM
Physician performed a colonoscopy on a Medicare patient but got to the hepatic flexure. Procedure report states it was an incomplete colonoscopy so do I need to use a modifier 53 and will there be a reduction in reimbursement? I thought as long as you go beyond the splenic flexure you can still bill for complete colonoscopy? Thanks - Oklahoma subscriber
SuperCoder Answered Tue 16th of August, 2016 23:41:41 PM


As mentioned by you, colonoscopy performed till splenic flexure is billable as a complete procedure but this rule was applicable prior to 2015,which stated, CPT® defined “incomplete colonoscopy” as a colonoscopy that did not evaluate the colon past the splenic flexure (the distal third of the colon). And physicians were instructed to report an incomplete colonoscopy with 45378-53, which was paid at the same rate as a sigmoidoscopy.

Lately, as of 2015, CPT® changed the definition of an incomplete colonoscopy to a colonoscopy that does not evaluate the entire colon. That is, the colonoscope is advanced past the splenic flexure but not to the cecum.

The 2015 CPT® codebook 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.”

Hope this Helps.


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