AAPC - Back to school
Results 1 to 4 of 4

Thread: Colonoscopy help please

  1. #1
    Join Date
    Apr 2007
    Northeast Kansas AAPC

    Default Colonoscopy help please

    AAPC: Back to School
    Medicare patient underwent colectomy 11-12-10

    DOS: 3-16-11
    PREOP DIAGNOSIS: Possible stricture of rectal anastomosis.
    POSTOP DIAGNOSIS: Stricture of the area of the rectal anastomosis with no identifiable lumen.
    OPERATION: Colonoscopy

    INDICATIONS: This patient had a previous GI series of her lower tract. With barium, she was found to have a stricture at the rectosigmoid junction. This was felt to be fairly significant. For this reason, a colonoscopy is performed to see if we need to dilate this prior to taking down her ileostomy.

    OPERATIVE PROCEDURE: Under satisfactory prep with the patient sedated, the colonoscope was inserted in the anus. This was advanced to about 15-20 cm some fecal material was present. This was evacuated with the evacuator. After evacuating this, I could not find a lumen which can be cannulated or ballooned. Extensive attempts at cannulating the rectal stump or looking at this area did not reveal any openings. After about 15 minutes of trying this, the procedure was terminated. I believe the patient has a significant stricture of the rectosigmoid junction which would make it unsafe to close her ileostomy at this time. I will discuss further options with the family.

    Any ideas for CPT and ICD9??


  2. #2

    Smile colonoscopy

    the CPT code that you could use would be 45378 with the modifier 53 because the procedure was discontinued after 15 minutes. The cide the icd code as a rectum stricture or the rectosigmod stricture. Hope this helps,remember the colonoscopy did not take a biopspy or controlled bleeding.
    Last edited by rebmcdow; 03-28-2011 at 11:11 AM. Reason: correct spelling and grammar

  3. #3


    Do you code for the physician or the facility? Because I believe that can play a role in the modifier.

  4. #4
    Join Date
    Apr 2007
    Northeast Kansas AAPC


    this is for the physician only

Similar Threads

  1. Colonoscopy
    By BSCOTT@GIHEALTHCARE.COM in forum AAPC Coding Challenge
    Replies: 4
    Last Post: 05-06-2015, 02:56 PM
  2. Screening Colonoscopy vs Problem Colonoscopy
    By puggles in forum General Surgery
    Replies: 5
    Last Post: 03-25-2014, 06:08 AM
  3. Screening Colonoscopy versus Surveillance Colonoscopy
    By wsoler in forum Gastroenterology
    Replies: 19
    Last Post: 10-10-2013, 05:11 PM
  4. colonoscopy
    By ddebbied in forum Modifiers
    Replies: 3
    Last Post: 04-02-2009, 11:03 AM

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts

Enjoying Our Forums?

AAPC forums are a benefit of membership. Joining AAPC grants you unlimited access, allowing you to post questions and participate with our community of over 150,000 professionals.

Join Now Continue Reading Without Full Access

Already a Member?


Close Message

In addition to full participation on AAPC forums, as a member you will be able to:

  • Access to the largest healthcare job database in the world.
  • Join over 150,000 members of the healthcare network in the world.
  • Be a part of an industry leading organization that drives the business side of healthcare.
  • Save anywhere from 10%-50% with exclusive member discounts on courses, books, study materials, and conferences.
  • Access to discounts at hundreds of restaurants, travel destinations, retail stores, and service providers. AAPC members also have opportunities to save on heath, life, and liability insurance.
  • Become a member of a local chapter and attend regular meetings.