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perforation during colonoscopy

  1. #1
    Question perforation during colonoscopy
    Medical Coding Books
    I have two op reports that the doctor perforated the bowel during the colonoscopy. The first one was in the sigmoid colon, which after he felt the pop, he did an exploratory lap and fixed the perforation. When examining the colon since this person had blood in stool for awhile, he found that a portion of the colon was incarcerated in a left inguinal hernia that had to be extracted prior to delineating and repairing the perforation. What is chargeable?

    On the other op report this lady, he perforated at the rectosigmoid junction. The patient had a previous nephrectomy for apparently a third kidney as well as remote left oophorectomy with scar tissue in the left pelvis area. There were questions about her other ovary since she had elevated CEA. He fixed the perforation but also ended up taking her right ovary out, which was benign but mass like. Anyways I'm not sure what to charge for. Please help!

  2. #2
    I will touch on the 1st case scenario:

    I think I would code for the colonoscopy and the incarcerated hernia. I would not code for the exploratory lap because the surgeon caused the perforation. The reason I would code for the hernia is because this was an encountered problem that had to be fixed, not something caused by the surgeon.

    make sense?

  3. #3
    Yes, it makes sense, but would I put a -52 on the colonoscopy since he didn't go all the way to the cecum?

  4. #4
    if you are billing for the surgeon, then yes, the -52 is the appropriate modifier

  5. #5
    Thank you

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