Wiki Incomplete colonoscopy due to poor prep

[turtle694]

I have a colonoscopy that was unable to be completed because of poor prep. I was going to change to 45330 because they didn't make it past the splenic flexure. As I read the op note, they didn't make it past the rectum. The op note says that none of the colon was looked at because of poor prep. In this case would I just bill a rectal exam or would I bill a 45330 with a 53 modifier?

 

[mconner001]

Hi, have you looked at the CPT book for guidance on this? Page 378 has guidance and there is also a decision tree on page 381 (may or may not be helpful).

 

[turtle694]

I have there is nothing about when they don't even make it past the rectum

 

[MarDee]

Hi Turtle 694! I do believe mconner001 was pointing you in the right direction on p. 378 of CPT - guidance says: 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.

The -53 modifier lets them know it was discontinued so when it is re-scheduled, it can still be credited for the screening or for diagnostic purposes.

Hope that helps!!