Wiki Colonoscopy/sigmoidoscopy- suggestions, please


Deltona, FL
Best answers
Okay. This is the situation. Patient was scheduled for a colonoscopy. The dr was unable to complete. My question is...what do you think is the best way to bill this one out? The dr clearly states that he made multiple attempts, extra time, etc.

The patient was taken to the OR, after induction of adequate anesthesia, the patient was turned in the left lateral position. The digital rectal exam was unremarkable. The Olympus fiberoptic colonoscope was introduced per anus. I was able to pass through the rectum. The bowel prep was fair but with much irrigation it cleared adequately. I passed the scope through the rectum into the sigmoid colon. Severe diverticular disease was appreciated. Marked spasm was noted. The patient received Glucagon 1 mg x2 with some resolution of the spasm but I was unable to pass beyond 50 cm and was still was significantly diverticular affected sigmoid colon. After approximately 90 minutes of effort, repeated position changes, the procedure was abandoned. The scope was slowly withdrawn under direct vision. No significant mucosal abnormalities were noted though marked diverticular disease was seen.
The patient tolerated the procedure.
We will recommend a barium enema in this occasion and repeat colonoscopy to be considered in 5 years.
45378 w/a 53 modifier, you could also put on a 22 modifier based on the extra work to try to get the pt scoped, but I wouldn't.

dx=562.10 and whatever the indication for the procedure.