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Aborted Procedure

  1. #1
    Post Aborted Procedure
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    If a colonoscopy (45378) were planned, but discontinued for another day due to poor prep and the scope only reached the sigmoid colon, would the facility code 45378-74 or 45330-74? I'm unsure because the guidelines state to code as far as the scope reached, yet many articles show the code being 45378-74 for a discontinued colonoscopy yet they don't state just how far the scope went. Thanks in advance!



    Rich

  2. #2
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    Columbia, MO
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    If you get to the sigmoid but not beyound the splenic flexure then some facilites code it as the sigmoidoscopy with no modifier. However I always look to see if there is any result documented, and finding at all such all normal but could not continue, or does the documentation state that there was overall poorvisualization so the decision to abort was made. In that case code the colonoscopy with the 74 modifier.

    Debra A. Mitchell, MSPH, CPC-H

  3. #3
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    If the intent was for a colonoscopy, then I would code the 45378-74.

  4. #4
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    Yes, it was poor visualization due to poor prep. How does one determine if a sigmoidoscopy should be coded versus colonoscopy, when a discontinuation is made?

  5. #5
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    The standard here is if you get thru the sigmoid but not beyond splic flexure then it is by definition a sigmoidoscopy, but there needs to be something regarding finding or lack thereof to be a procedure otherwise call it discontinued.

    Debra A. Mitchell, MSPH, CPC-H

  6. #6
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    Thanks Debra! In this case, the surgeon documented "The perianal and digital rectal exams were normal. Normal sphincter tone. Normal mucosa was found at 30cm. proximal to the anus." I'd code 45330 without modifier 74?

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