PNChowdary
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- Messages
- 2
- Location
- Guntur, Andhra Pradesh
Hi Everyone,
I'm looking for clarification on the correct coding in the following scenario.
The provider initially intended and documented the procedure as a sigmoidoscopy, but during the procedure the scope was advanced beyond the splenic flexure into the transverse colon, and a biopsy was performed in the transverse colon.
Based on the CPT colonoscopy decision tree, since the scope passed beyond the splenic flexure, I would consider reporting 45380-52 (colonoscopy with biopsy, reduced services) because the procedure reached colonoscopy territory but did not reach the cecum.
My question is regarding the documentation requirements. The provider did not document the reason the scope was not advanced to the cecum (e.g., poor prep, obstruction, patient intolerance, etc.).
Should we still report 45380-52 based solely on the anatomical extent of the examination (scope advanced beyond the splenic flexure with biopsy), or is documentation of why the colonoscopy was incomplete required in order to support coding an incomplete colonoscopy with modifier 52?
In other words, does the coding decision depend primarily on the location reached according to the colonoscopy decision tree, or must the provider also clearly document the reason the procedure was not completed to the cecum?
I would appreciate any guidance, references, or coding clinic guidance that addresses this situation.
Thank you!
I'm looking for clarification on the correct coding in the following scenario.
The provider initially intended and documented the procedure as a sigmoidoscopy, but during the procedure the scope was advanced beyond the splenic flexure into the transverse colon, and a biopsy was performed in the transverse colon.
Based on the CPT colonoscopy decision tree, since the scope passed beyond the splenic flexure, I would consider reporting 45380-52 (colonoscopy with biopsy, reduced services) because the procedure reached colonoscopy territory but did not reach the cecum.
My question is regarding the documentation requirements. The provider did not document the reason the scope was not advanced to the cecum (e.g., poor prep, obstruction, patient intolerance, etc.).
Should we still report 45380-52 based solely on the anatomical extent of the examination (scope advanced beyond the splenic flexure with biopsy), or is documentation of why the colonoscopy was incomplete required in order to support coding an incomplete colonoscopy with modifier 52?
In other words, does the coding decision depend primarily on the location reached according to the colonoscopy decision tree, or must the provider also clearly document the reason the procedure was not completed to the cecum?
I would appreciate any guidance, references, or coding clinic guidance that addresses this situation.
Thank you!