Wiki Correct way to code this incomplete colonoscopy

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jdibble

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I am hoping that someone could please help with this question and provide some guidance on incomplete colonoscopy coding. We have a patient who had a colonoscopy that could not be completed and we are unsure the correct way to code this! The following is the documentation:

Examination of the colon revealed moderate/severe medium and large mouthed diverticulosis was observed in the sigmoid colon without signs of active inflammation/bleeding. A colonic stricture was observed about 45 cm from the anal verge, unable to pass scope through the stricture. Retroflexion in the rectum showed medium size internal hemorrhoids. The colonoscope was then removed and the procedure was terminated.

This patient is a Medicare patient. Would this be coded with a 53 modifier? Or would this be coded with the sigmoidoscopy code 45330? Would it matter who the payer is as to how to code? Another question - is there a difference in how it is coded depending on if they did or didn't go beyond the splenic flexure and would the doctor have to actual say that they did or did not go beyond the splenic flexure?

Thank you for all answers to my questions! It is appreciated!
 
First I would look at the intent of the procedure . If it was for 45378 , I would bill 45378 w/ a 53 modifier. And if you were to bill a sigmoidoscopy , no modifier needed.
And on the 2nd question, yes the documentation should state how far the scope went to determine the cpt code to use.
 
lcolborn said:
First I would look at the intent of the procedure . If it was for 45378 , I would bill 45378 w/ a 53 modifier. And if you were to bill a sigmoidoscopy , no modifier needed.
And on the 2nd question, yes the documentation should state how far the scope went to determine the cpt code to use.
Click to expand...
Thanks for the response.

If you could just clarify for me the correct way to code a colonoscopy that does not go beyond the splenic flexure - would it still be the CPT code with 53 or would that now be coded as a sigmoidoscopy with 45330 (I understand no 53 modifier on this code)? This is for a Medicare patient - not sure if it is different depending on the payer.

Thank you again!
 
And so, the splenic flexure is the first bend in the colon..., on a regular Colonoscopy, where the scope only met the splenic flexure w/o any obstruction or reason not to go any further , it should be coded as sigmoidoscopy ( exam of the entire rectum , sigmoid colon and may include a portion of the descending colon). I always keep in mind to code it based on the area where the scope reached and the intent of the procudere. A full colon is all the way to the cecum etc.
In your colonoscopy case above, it was discontinued due to the obstruction and the intent was a full colonoscopy that's why it was coded as 45378(53). Now, in some cases that they decided to bring them back, the insurance co. will see that 45378 (53) was already billed and it was incomplete, so therefore they will pay for the next one.
 
lcolborn said:
And so, the splenic flexure is the first bend in the colon..., on a regular Colonoscopy, where the scope only met the splenic flexure w/o any obstruction or reason not to go any further , it should be coded as sigmoidoscopy ( exam of the entire rectum , sigmoid colon and may include a portion of the descending colon). I always keep in mind to code it based on the area where the scope reached and the intent of the procudere. A full colon is all the way to the cecum etc.
In your colonoscopy case above, it was discontinued due to the obstruction and the intent was a full colonoscopy that's why it was coded as 45378(53). Now, in some cases that they decided to bring them back, the insurance co. will see that 45378 (53) was already billed and it was incomplete, so therefore they will pay for the next one.
Click to expand...
Thank you! :)
 
I have a colonoscopy that was unable to be completed because of poor prep. I was going to change to 45330 because they didn't make it past the splenic flexure. As I read the op note, they didn't make it past the rectum. The op note says that none of the colon was looked at because of poor prep. In this case would I just bill a rectal exam or would I bill a 45330 with a 53 modifier?
 
As I was reading this , I was gonna agree on 45330, however you said they didn't make it past the rectum..., and I'm positive they are coming back,
and so I am leaning more on 45300 based on what info you have given.
 
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