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Coding help!!!

  1. #1
    Default Coding help!!!
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    I have a physician who did a disimpaction of a large volume of retained rectal material and rigid sigmoidoscopy. I'm not sure if the removal of impaction would include the sigmoidoscopy or the opposite.

  2. #2
    Default
    I got 45307 and 49515 - These 2 codes trigger OCE edit 0020:

    (49515) This code is a component of comprehensive procedure 45307 and is not allowed even if appropriate modifier is present.

    If that helps...

  3. #3
    Default
    Could you use modifier 22 on the sigmoidoscopy?

  4. #4
    Default
    i did look at both codes 45307 and 45915.

    Procedure note:
    After suitable positioning of the patient in the operating room, IV sedation was administered. The rectal area was lubricated and using digital manipulation, a large amount of retained rectal material, no stool was removed. This was a fairly large volume equating to approximately 1 liter in volume. After removal of all palpable material, a sigmoidoscopy was carried out, revealing several other small pieces of this material in the upper part of the rectal area. This was retrieved with a grasper, leaving only a miniscule amount in the proximal portion of the rectum. There were no mucosal lesions senn on examination of the rectal area. There were some small hemorrhoids which were not bleeding. There was a tiny anal tear which was very superficial that was present.

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