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HELP ! How to code a colonoscopy when there is no colon?

  1. #1
    Question HELP ! How to code a colonoscopy when there is no colon?
    Medical Coding Books

    Doctor performed a "colonoscopy" on patient status-post ileal-pouch anal anastamosis. Only the anal canal, ileal pouch, and a small portion of the ileum were viewed. No biopsies were taken.

    The doctor wants to code a flex-sig, but I don't think that this applies since there is no sigmoid colon, or any other for that matter. Would a 44385, endoscopic evaluation of small intestinal pouch; work with this procedure?

    Any thoughts?

  2. Default
    I would go with 44385 based on the info you gave

  3. Default
    Here is the description for 44385: The physician examines a pouch in the small intestine by inserting an endoscope into the abdominal cavity.

    If your provider is going through the anus this code is not going to work. We usually use one of the 453XX codes, depending on the situation and how much is being evaluated, and add a modifier 52 for reduced services since the entire colon/intestine is missing. Also use V45.3 as one of your Dx's

  4. #4
    Default colonscopy when there is no colon
    44385 is correct. The endoscope may be advanced through the anus or existing stoma to examine the intestinal pouch.

    Michele R. Hayes, CPC, CPMA, CEMC, CGIC

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