Gastroenterology Coding Alert

Question: How is a “colonoscopy” coded on a patient who has had a total proctocolectomy with ileoanal pull through? The performing physician calls it a colonoscopy on the operative report and a pouchoscopy on the schedule. The original ordering physician placed the order for a sigmoidoscopy. The op report reads as below:

Procedure: Colonoscopy

The Colonoscope was introduced through the anus and advanced to the terminal ileum.

Findings:

J pouch with normal appearing small bowel anastomosis of small bowel and anus about 10 mm with small fistula opening. The terminal ileum appeared normal.

Michigan Subscriber

Answer: It is certain that you are getting confused because of your physician using multiple terms such as “colonoscopy” and “pouchoscopy” for the same procedure. However, the findings that you have described in the operative report in your question shows very clearly that your physician is performing the procedure to visualize the J pouch that had been created during the previous proctocolectomy procedure. Therefore, the procedure that your physician performed is a pouchoscopy although he refers to it by various terms.

So you will have to report 44385 (Endoscopic evaluation of small intestinal [abdominal or pelvic] pouch; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]) to describe the visualization of the J pouch that your physician performed.