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  1. #1
    Default 45378??
    Medical Coding Books
    written informed consent was obtained, and the procedure was performed in the endoscopy unit. The patient was placed in the left lateral position, and a digital rectal examination was performed, which was unremarkable.

    A videocolonoscope was then introduced from the anal opening into the anal canal, and the scope was advanced from the rectum to the rectosigmoid area.

    The scope was then further advanced into the transverse colon, and close to what seemed like to be the hepatic flexure. However, it was extremely difficult for me to negotiate the scope beyond the tortuous looping that kept recurring most likely in the sigmoid region. The scope was withdrawn back several times, and the patient's position was changed from left lateral to supine, and then to right lateral. However, in spite of several attempts to negotiate the scope further up, we could not negotiate into the right side of the colon. It was therefore decided to withdraw the scope back.

    The scope was slowly withdrawn, carefully looking at all of the folds. No other abnormalities could be identified. Minimal internal hemorrhoids were noted. The rest of the left colon appeared unremarkable.

    1. Significant fixed looping with tortuous colon.
    2. Exam completed only up to likely mid transverse colon.

    it passed the splenic flex so would I bill it for a regular colonoscopy???
    Commercial carrier

  2. #2
    Charlotte, NC
    yes. since the note states the docot moved into the transverse colon which is past the splenic flexure. You could, I guess, use a 52 modifier.....but I wouldn't see the need.

    cpt 2010:
    "45378 Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen(s)....."

    cpt 2010 professional edition

    "a colonoscope is inserted in the anus and move through the the colon past the splenic flexure in order to visualize the lumen of the rectum and colon."

  3. #3
    Thank you

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