45378-52 or a 44360

[suzannereed]

Which code is correct? The op report states procedure performed "attempted colonoscopy which is converted to a left-side colonoscopy." The report states "in the left lateral decubitus position a Fujinon videocolonoscope was placed in the rectal vault and advanced to 70cm but were challenged with pelvix fixation of the sigmoid colon, loss of mobility, and inability to safely or comfortably proceed down to this point. We did not identify landmarks of the transverse colon or the splenic flexure. I believe we probably examined the left colon with entirety and its mucosa was normal. There was no diverticular disease. No mass lesion. No inflammatory disease. In scope retroflexion of the rectal vault was normal. Impression; Pelvic fixation precluding and limiting total colonoscopy to the cecum." Any thoughts on this? I am leaning towards a 45378-52 with op report included. Please help.

 

[FTessaBartels]

53 modifier

I would use a -53 modifier. The physician did not plan to perform a reduced service, he had to terminate the procedure due to difficulty/problem.

Oh, and YES .. include the procedure note.

Just my opinion.

F Tessa Bartels, CPC, CEMC

 

[suzannereed]

I got the idea of the 52 modifer from page 231 in the CPT book. It states "For an incomplete colonscoy, with full preparation for a colonoscopy, use a colonscopy code with the modifer 52 and provide documentation." Any thoughts on this?

 

[helenadutoit@comcast.net]

I would suggest you use 45378-53, since the scope did not pass the splenic flexure. This modifier is for the professional side, for the facility you would use the 74 modifier. You should get paid in full.