CMS to Implement Fix for Anesthesia Payments for Colonoscopies

UPDATE:  New information from CMS on denials of claims for anesthesia for screening endoscopy that becomes diagnostic (Code 00810 with modifier PT)

As previously reported, ASA notified the Centers for Medicare and Medicaid Services (CMS) that claims for anesthesia services for screening colonoscopy that becomes diagnostic (reported with code 00810 with modifier PT as instructed in the CY2015 Final Rule on the Medicare Physician Fee Schedule) were being denied because the CPT code was not consistent with the modifier.

In a notice on April 3, CMS issued updated guidance stating:

Effective for claims with dates of service on or after January 1, 2015, contractors shall continue to recognize and pay HCPCS code 00810, Anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum.

Effective for claims with dates of service on or after January 1, 2015, contractors shall update their systems to recognize, accept, and be capable of processing modifier 33 for appropriate claims processing purposes.

Effective for claims with dates of service on or after January 1, 2015, contractors shall not apply deductible and coinsurance to claim lines for HCPCS 00810 services when billed with modifier 33 and shall not apply the deductible when HCPCS anesthesia code 00810 is submitted with the PT modifier.

The deductible is also not applied when modifier PT is appended to at least either one of the CPT codes within the surgical range of CPT codes (10000-69999) or HCPCS codes G6018-G6028 on the claim for services that were furnished on the same date of service as the procedure.

Effective with dates of service on or after January 1, 2015, contractors shall continue to apply deductible and coinsurance to claim lines HCPCS 00810 services billed without modifier 33 or modifier PT.

The full transmittal is available here. MLN Matters Number MM8874 has been revised to reflect this new information and is available here.

ASA will post further information on resolution of previously denied claims as it becomes available from CMS.