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Physician coding for termination of multiple procedure

  1. Default Physician coding for termination of multiple procedure
    Medical Coding Books
    Hi,
    My physician did an EGD(43239) and attempted to do a colonoscopy. During the same operative session, pt still under anesthesia he attempted to perform a colonoscopy. He performed a digital rectal exam which some "retained solid stool as well as a significant amount of melenic liquid stool indicating the prep was inadequate and colonoscopy would be impossible therefore it was not perfomed."

    For physician billing can I code the colonoscopy at all?

    Marci Klaubauf, CPC

  2. #2
    Default
    you can append the modifier -53 to your colonoscopy code
    Walker Bachman, CPC, CPPM

  3. #3
    Default
    the April 2009 Coding Edge had an article regarding screening colonoscopies, they state also "Note that payers who follow CPT® rules require modifier
    52 Reduced services, not modifier 53, for an incomplete
    colonoscopy." Otherwise to my knowledge Medicare is modifier 53.

  4. #4
    Default
    Thanks Lisa.. I missed that somehow. Good information...
    Walker Bachman, CPC, CPPM

  5. #5
    Location
    Milwaukee WI
    Posts
    4,466
    Default He didn't even insert the scope?
    Are you telling me that you are going to try to bill for an "incomplete" colonscopy when he didn't even insert the scope? All he did was a digital rectal exam.

    I wouldn't code the colonscopy at all.

    F Tessa Bartels, CPC, CEMC

  6. Default
    Do you think I could code 45990 Anorectal exam, surgical requiring anesthesia?
    Marci

  7. #7
    Default
    Quote Originally Posted by FTessaBartels View Post
    Are you telling me that you are going to try to bill for an "incomplete" colonscopy when he didn't even insert the scope? All he did was a digital rectal exam.

    I wouldn't code the colonscopy at all.

    F Tessa Bartels, CPC, CEMC
    good point... I agree
    Walker Bachman, CPC, CPPM

  8. #8
    Location
    Milwaukee WI
    Posts
    4,466
    Default Here's the lay description
    Quote Originally Posted by Mklaubauf View Post
    Do you think I could code 45990 Anorectal exam, surgical requiring anesthesia?
    Marci
    No. DRE is usually part of an E/M service. I wouldn't code anything for this "procedure."

    Here's the lay description from Encoder Pro

    CPT 45990: The physician performs a diagnostic anorectal exam. The patient is placed under general, spinal or epidural anesthesia. The physician examines the external perineal area. A pelvic examination is performed when appropriate. A digital rectal exam is performed. An anoscope is inserted into the rectum. The anal canal and distal rectum are visualized. The anoscope is removed and a rigid proctosigmoidoscope is inserted into the anus and advanced. The sigmoid colon and rectal lumen are visualized. The proctosigmoidoscope is removed.

    F Tessa Bartels, CPC, CEMC

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