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Thread: question on incomplete procedure

  1. #1
    Join Date
    Apr 2007
    Location
    Des Moines
    Posts
    313

    Default question on incomplete procedure

    Patient had a polyp removed (45380) on 01/27. Patient comes back on 03/14 for a planned ileostomy reversal. The surgeon aborts the procedure- I'm confused- It looks like a colonoscopy? Any thoughts? Do I used a modifier on it for planned procedure?

    Patient brought to endoscopy suite for a planned ileostomy reversal... patient placed on table...anesthesia induced...rigid sigmoidoscope was inserted to confirm patency of anastomosis prior to reversal...anastomosis was encounted at 8 to 10 tightly strictured... sigmoidoscope failed...then a pediatric caliber sigmoidoscope was advanced...colon on other side of anastomosis was inflamed...pediatric scope was withdrawn and exchanged for a flexible EGD scope...this was passed through dilating up to the size of the EGD scope...this was exchanged for a colonoscope for larger diamter...this was passed through the anastomosis with a slight popping sensation dilating to the diameter of the scope. Scope was withdrawn and decision to abort the ileostomy take-down in light of the stricture... Plan for re-scope in 6-8 weeks.


    Brooke Bierman, CPC, CPB
    Coding & Billing Manager
    2014 President AAPC Des Moines Chapter

  2. #2
    Join Date
    Apr 2007
    Location
    Atlanta
    Posts
    335

    Default

    Quote Originally Posted by babierman View Post
    Patient had a polyp removed (45380) on 01/27. Patient comes back on 03/14 for a planned ileostomy reversal. The surgeon aborts the procedure- I'm confused- It looks like a colonoscopy? Any thoughts? Do I used a modifier on it for planned procedure?

    Patient brought to endoscopy suite for a planned ileostomy reversal... patient placed on table...anesthesia induced...rigid sigmoidoscope was inserted to confirm patency of anastomosis prior to reversal...anastomosis was encounted at 8 to 10 tightly strictured... sigmoidoscope failed...then a pediatric caliber sigmoidoscope was advanced...colon on other side of anastomosis was inflamed...pediatric scope was withdrawn and exchanged for a flexible EGD scope...this was passed through dilating up to the size of the EGD scope...this was exchanged for a colonoscope for larger diamter...this was passed through the anastomosis with a slight popping sensation dilating to the diameter of the scope. Scope was withdrawn and decision to abort the ileostomy take-down in light of the stricture... Plan for re-scope in 6-8 weeks.
    If you are billing for physician then use modifier 53, if coding for facility 74

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