Starting with January 1, 2018, dates of service, anesthesia services for common gastrointestinal endoscopic procedures have been replaced with new CPT codes which more specifically define the location and nature of the procedure. Two of those codes used for colonoscopies were recently highlighted by the Centers for Medicare and Medicaid Services (CMS) to clarify how they should be billed to and will be reimbursed by Medicare.
Anesthesia services furnished in conjunction with screening colonoscopies should be reported to Medicare with CPT code 00812 (Anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum; screening colonoscopy). Medicare will then waive the deductible and coinsurance when paying for the anesthesia service.
When a screening colonoscopy becomes a diagnostic colonoscopy, the anesthesia service should be reported to Medicare with CPT code 00811 (Anesthesia for lower intestinal endoscopic procedures, endoscopy introduced distal to duodenum; not otherwise specified) and with the PT modifier, indicating the procedure began as a screening colonoscopy. In that case, Medicare will waive only the deductible when paying for the service.
According to NPR’s Michelle Andrews, a screen colonoscopy becomes a diagnostic colonoscopy “if a polyp is found during the test.” Medicare will cover a screening colonoscopy once every 2 years (24 months) for patients at high risk for colorectal cancer. For patients not at high risk, Medicare will cover a screening colonoscopy once every 10 years (120 months), or every 4 years (48 months) after a previous flexible sigmoidoscopy. Patients are considered high risk for colorectal cancer if they have any of the following:
- A close relative (sibling, parent, or child) who has had colorectal cancer or an adenomatous polyp;
- A family history of adenomatous polyposis;
- A family history of hereditary nonpolyposis colorectal cancer;
- A personal history of adenomatous polyps;
- A personal history of colorectal cancer;
- A personal history of inflammatory bowel disease, including Crohn’s Disease and ulcerative colitis.
The new codes are being implemented for GI anesthesia procedures because CMS flagged the original two codes, 00740 – Upper GI and 00810 – Lower GI, as potentially misvalued. In order to address the valuation problems for 2018, CMS deleted the original codes and created the new ones. In the process, they also adjusted the base units of these procedures. For Upper GI procedures, the base units held steady or increased. However, for lower GI procedures, including the the two mentioned above for colonoscopies, the base units drop by one or two points, which represents a 20 to 40 percent reduction.
For more information about how to bill screening colonoscopies to Medicare, review MLN Matters Number: MM10181.
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