Gastroenterology Coding Alert

Question: A patient is prepared for total colonoscopy. However, during the procedure, the provider is not able to advance the colonoscope to the cecum. How do we code for this scenario?

Mississippi Subscriber

Answer: The codes will depend on the type of procedure being performed, whether diagnostic or therapeutic. In the past a colonoscopy passing the splenic flexure was considered adequate to report the full procedure code however beginning in 2016 the definition of a complete colonoscopy now must include reaching the cecum unless it is absent or unreachable due to an identified obstructing lesion. Inability to reach the cecum due to technical difficulty means the procedure was incomplete.

In cases when the provider was performing a diagnostic or screening endoscopic procedure and was unable to advance the colonoscope to the cecum, you may report CPT® 45378 (Colonoscopy, flexible; diagnostic, including collection of specimen[s] by brushing or washing, when performed [separate procedure]) with modifier 53 (Discontinued procedure). In addition, you must remember to provide appropriate documentation of the service provided.

If the provider performed therapeutic colonoscopy and same situation occurred, you may report the appropriate therapeutic flexible colonoscopy code such as 45380-45398, with modifier 52 (Reduced services), along with the needful documentation describing the situation and why the procedure could not be completed.