Flex Sigmoidoscopy

wcarmignani

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I bill and have begun to code for General Surgery and sometimes our doctors do colonoscopies and sigmoidoscopies. My question is when the doctor preforms a flex sig and only advances to the rectum (doctors choice no complications) should it be billed with a modifier due to the fact that the CPT definition for a sigmoidoscopy is "examination of entire rectum, sigmoid colon, and may include examination of a portion of the decending colon"?

Thanks
 

elenax

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Stuart
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That is interesting; I would like to hear some feedback as well. I have not come across one like that where it was the doc 'choice'.
 

wcarmignani

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Here is an excerpt from the report:

Procedure: Lower EUS
Indications: Post-operative endosonographic surveillance for potential tumor recurrence

Flexible sigmoidoscope was introduced through the anus and advanced to the rectum. The lower EUS was accomplished with ease. The patient tolerated the procedure well. The quality of the bowel preparation was good.

Findings:
Endosonographic Finding -The rectum was normal. -The perirectal
space was normal. -No lymph nodes were seen in the perirectal region
during endosonographic examination of the rectum.

Impression:- Endosonographic images of the rectum were unremarkable.
- Endosonographic images of the perirectal space were unremarkable.
Recommendation: - Discharge patient to home (ambulatory).
- Return to endoscopist in 4 months.

CPT Code(s): 45341, 74, Sigmoidoscopy, flexible; with endoscopic
ultrasound examination
ICD Code(s): V67.00, Follow-up examination, following unspecified
surgery


I see the physician put the mod 74 but there were no circumstances that caused the procedure to be halted so I wasn't sure if I should bill the 45341 with a 52 since he only examined the rectum per his own discretion.
 
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52 modifier

If you are billing for the physician, the modifier should be -52.
Sounds as if he planned to do only the lower portion; it wasn't discontinued due to complications or other factors.

F Tessa Bartels, CPC, CPC-E/M
 
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