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colonoscopy after colon resection

  1. #1
    Default colonoscopy after colon resection
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    I need help on this colonoscopy. This lady has had a colon resection d/t invasive adenocarcinoma, leaving her with essentially just the rectum and the distal 5-10 cm of her sigmoid colon. The scope was advanced roughly 25 cm to what appeared to the the anastomosis. There were two small polyps, one 2-3mm in size and 1mm in size. Polypectomies were performed with cold biopsy forceps. The scope was readily advanced another 25-30 cm into the small bowel, no evidence of any other lesions. The scope was withdrawn.

    So, not sure what to code....any suggestions would be helpful.


  2. Default
    I think you would need to go with the Flexible sigmoidoscopy codes instead of a colonoscopy.

    I would go with 45331 Flex Sig with biopsy single or multiple.
    Rachell Lindley, CPC
    Multispecialty Clinic Coding
    Internal Medicine
    General Surgery
    Family Medicine

  3. Default
    my question is, what was the physicians point of entry? was it the rectum or the colostomy site? did patient even have a colostomy? your note is confusing in that you say the rectum and sigmoid were viewed up to anastamosis- then two polyps removed by cold biopsy- and then the scope was advanced to the distal small bowel, this sounds like a full colonoscopy to me if the physician entered thru the rectum it is a full colonoscopy of 45380

    if the physician did not enter thru the rectum but thru the stoma then you have to refer to colonoscopy thru stoma with biopsy 44389

    To me though, from what i can tell by your description, the doctor did a full colonoscopy with biopsy x2 by cold forceps which is 45380

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