Gastroenterology Coding Alert

Question: A patient with abdominal distention reported to the office. The gastroenterologist performed a colonoscopy and was concerned about perforation when he found that the patient's abdomen was filling with gas. There turned out to be no bleeding or perforation, but can we report anything other than a diagnostic colonoscopy?

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Answer: In your scenario, the gastroenterologist performed a colonoscopy, searched for signs of a perforated colon and found none. That is a diagnostic colonoscopy, which should be reported with 45378 (Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen[s] by brushing or washing, with or without colon decompression [separate procedure]).
 
Exception: However, if the gastroenterologist corrected a problem during the colonoscopy (that is, bleeding, polyp removal, submucosal injection, etc.), you would not report a diagnostic colonoscopy. Let's say the doctor found a polyp and ablated it during the colonoscopy; you should report 45385 (... with removal of tumor[s], polyp[s], or other lesion[s] by snare technique).