The Centers for Medicare & Medicaid (CMS) has issued a revision to MM8874regarding anesthesia furnished in conjunction with a colonoscopy on April 3 with a Jan. 1, 2015 effective date. 

By appropriately appending the modifier PT to Anesthesia services for a screening colonoscopy that becomes diagnostic (reported with code 00810 and modifier PT), the patients payment responsibility will be correctly reflected. These were previously being denied because the CPT code was not consistent with the modifier.

CMS Makes Revisions to Policy for Anesthesia Furnished in Conjunction with Colonoscopy

Claims previously denied that qualified for the PT modifier are being reprossessed based on the individual Medicare Administrative Contractors (MACs) guidance either automatically or through appeals.

Insufficient documentation can cause continued denials

The above will address the incorrect denials associated with the placement of the PT modifier when correctly appended, as well as address the patient’s true financial responsibility. However, it’s important to note that it will not address denials that may occur due to insufficient documentation to indicate if it’s a Screening or a Diagnostic service. Some MACs are comparing the “anesthesia” billed service against the “surgeons” billed service and if different, a denial could occur. 

Examples of denials that could occur: 

  • No surgeon’s claim has been received yet
  • Surgeon’s claim was received, but G0105 or G0121 was not submitted. Instead, a code from the 453XX series, communicating a diagnostic colonoscopy service, which if occurs during a screening colonoscopy should have modifier “PT” appended.

It’s extremely important to properly document a screening colonoscopy. When a patient presents for a screening colonoscopy (i.e., no signs or symptoms prompting the service), the anesthesia record must clearly identify the service as a screening service with a preoperative diagnosis documented as “screening” and/or the procedure documented as a “screening colonoscopy.” 

Where a screening colonoscopy turns diagnostic (i.e., a biopsy or polyp/lesion is removed), this must be properly documented on the anesthesia record for appropriate capture by the coder. Failure to do so will undoubtedly cause delays in claims processing as well as increase the risk of future issues should the MAC not utilize a proactive process for matching up surgeon and anesthesiology service prior to payment.

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About the author

Mary Jo Gross, CPC, CANPC of Compliance – Anesthesia and Pain Management, McKesson Business Performance Services