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Old 04-17-2012, 09:37 AM
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Default question on incomplete procedure

Patient had a polyp removed (45380) on 01/27. Patient comes back on 03/14 for a planned ileostomy reversal. The surgeon aborts the procedure- I'm confused- It looks like a colonoscopy? Any thoughts? Do I used a modifier on it for planned procedure?

Patient brought to endoscopy suite for a planned ileostomy reversal... patient placed on table...anesthesia induced...rigid sigmoidoscope was inserted to confirm patency of anastomosis prior to reversal...anastomosis was encounted at 8 to 10 tightly strictured... sigmoidoscope failed...then a pediatric caliber sigmoidoscope was advanced...colon on other side of anastomosis was inflamed...pediatric scope was withdrawn and exchanged for a flexible EGD scope...this was passed through dilating up to the size of the EGD scope...this was exchanged for a colonoscope for larger diamter...this was passed through the anastomosis with a slight popping sensation dilating to the diameter of the scope. Scope was withdrawn and decision to abort the ileostomy take-down in light of the stricture... Plan for re-scope in 6-8 weeks.
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Old 04-17-2012, 10:19 AM
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Quote:
Originally Posted by babierman View Post
Patient had a polyp removed (45380) on 01/27. Patient comes back on 03/14 for a planned ileostomy reversal. The surgeon aborts the procedure- I'm confused- It looks like a colonoscopy? Any thoughts? Do I used a modifier on it for planned procedure?

Patient brought to endoscopy suite for a planned ileostomy reversal... patient placed on table...anesthesia induced...rigid sigmoidoscope was inserted to confirm patency of anastomosis prior to reversal...anastomosis was encounted at 8 to 10 tightly strictured... sigmoidoscope failed...then a pediatric caliber sigmoidoscope was advanced...colon on other side of anastomosis was inflamed...pediatric scope was withdrawn and exchanged for a flexible EGD scope...this was passed through dilating up to the size of the EGD scope...this was exchanged for a colonoscope for larger diamter...this was passed through the anastomosis with a slight popping sensation dilating to the diameter of the scope. Scope was withdrawn and decision to abort the ileostomy take-down in light of the stricture... Plan for re-scope in 6-8 weeks.
If you are billing for physician then use modifier 53, if coding for facility 74
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