Question Colonoscopy on patient in OR for colon resection


Olympia, Washington
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Hi, this is new for me. Our provider was called emergently into the OR as the surgical team needed assistance localizing a mass that was previously found in the colon. The patient was scheduled for a laparoscopic colon resection and the surgeon (different practice) could not locate the mass where the op report indicated. Our provider did a colonoscopy to find it. My question is regarding the use of a modifier. Do I use a 79 or something else? Or none at all?

This is a little tricky because i do not have the OP note to decipher which provider did what. If your provider did an intraoperative colonoscopy to find the mass (which would be diagnostic) you can use the 58 modifier on the colonoscopy code, but using the 58 modifier with the colonoscopy ONLY will result in a denial, if your provider helped with the mass as well this would be different. If this was a hospital call, and your doctor is not related to the other doctor I would say this could be a co- surgery (mod 62) since both providers were needed "simultaneously" to perform this procedure but you would need two separate OP notes to bill for modifier 62.

If you would like to send me more information i would be glad to take a look at it and i may be able to help a little more.
I appreciate the help.
Here, in part, is info from my providers colonoscopy. "presents with a history colon mass reportedly in ascending colon. Was called emergently to the OR patient intraoperatively was having resection of reported ascending colon mass. Surgical team asked for assistance localizing lesion. Patient reportedly had colonoscopy 12/27/2021. Colonoscopy report notes mass in the ascending colon.
PROCEDURE: The patient was in operating room supine draped. The colonoscope was inserted into the anus and advanced under direct vision to cecum, which was identified by the ileocecal valve. The quality of the colonic preparation was good .
Rectal exam: Small internal hemorrhoids, otherwise normal
Diverticuli throughout the colon most dense in sigmoid and descending colon.
Area of tissue edema previously noted in proximal sigmoid colon was seen. Area was again biopsied and area marked with India ink tattoo.
Repeated passes were made of the ascending colon, no mass was seen, however a 1 to 1.5 cm lesion with depressed center was seen in the cecum.
Otherwise normal colon.
1) 1 to 1.5 cm anterior lesion in cecum this likely represents area of previous biopsy showing high-grade dysplasia suspicious for invasive adenocarcinoma.
2) Area of likely mucosal edema in the sigmoid colon this was biopsied and area marked with India ink
3) Diverticulosis throughout the colon, most prominent in sigmoid descending colon"

The surgeons notes, in part:
1. Rigid sigmoidoscopy
2. Diagnostic laparoscopy
3. Intraoperative colonoscopy by Dr. Merrifield
4. Open right hemicolectomy
Procedure in Detail: With informed consent, the patient was brought to the operating room and placed supine where general anesthesia was established. She was positioned in lithotomy. Digital rectal exam and rigid sigmoidoscopy was performed to 20 cm. There was tortuosity of the sigmoid colon but no severe inflammation or stenosis.
After routine prep and drape, a surgical pause was undertaken.
A supraumbilical incision was made and the fascia grasped and elevated. A Veress needle was inserted and the abdomen insufflated. A noncutting trocar was placed and the laparoscopic camera inserted. The peritoneal cavity was examined. There was no evidence of needle or trocar injury. The remaining ports were placed under direct vision. The liver was examined and was unremarkable. The expected location of the lesion was examined. No evident mass can be seen. The entire colon from the cecum to the peritoneal reflection was examined and there was no evidence of mass. The supraumbilical incision was extended and a GelPort placed. A hand was introduced and the entire colon palpated. Again no mass was detectable. Dr. Merrifield was consulted and intraoperative colonoscopy was performed. The anticipated lesion was not obvious. A mass was identified in the proximal ascending colon but was not initially clear that this represented the lesion of concern. Dr. Merrifield performed complete colonoscopy. The area of concern was noted in the sigmoid colon. It was unclear whether this represented a polyp versus a mucosal fold which had been traumatized by the colonoscopy. He performed a biopsy and marked the site with India ink. After careful examination of the entire colon it was determined that the lesion in the ascending colon was the lesion of concern. The site was marked degree with a silk suture with the colonoscope in place. At this point, there is marked insufflation of the entire colon and most of the small bowel making laparoscopy impossible. The procedure was converted to open right hemicolectomy. The transverse colon was skeletonized and divided with the GIA stapler. In the transverse mesocolon was dissected and the vascular pedicle of the right colon divided and suture ligated at its origin. The hepatic flexure and right colon were mobilized. The terminal ileum was divided with the stapler. The remaining mesentery was divided and the specimen submitted for pathologic examination. The mesenteric defect was closed with 3-0 silk suture. A stapled anastomosis was created with the GIA stapler and the enterotomy closed with a TA stapler. Thickening of the distal 20 cm of terminal ileum was noted and some erythema of the mucosa. On inspection at the time of the anastomosis, this continued well proximally into the ileum and it was not felt appropriate to perform extensive resection. The bowel appeared viable for the anastomosis. The corner of the staple line was reinforced with a silk suture. Hemostasis was confirmed. The abdomen was irrigated. The omentum was returned to its normal position. The midline fascia was closed with #1 PDS. The midline incision was closed with staples and the laparoscopic port sites with subcuticular sutures.

Thank you for providing this information. Like i stated above this could be tricky because it looks like the providers information for the colonoscopy was "within" the note of the other provider and this would be considered an assist at surgery, but 45378 does not allow an assist so it would be included in the primary procedure. If he is a separate specialty, separate office he would have to dictate his own note. So, if he did dictate his own note, separate from the other providers note i would just bill for 45378 for his work as a full colonoscopy, because that is what he did.