Gastroenterology Coding Alert

Question: Our doctor attempted a colonoscopy with decompression. He passed the splenic flexure and saw stool in the transverse colon. However, he never got past the transverse colon and did not see the ascending colon. Is this an incomplete colonoscopy (45378-53) or a sigmoid-oscopy with decompression (45337)?


Pennsylvania Subscriber

Answer: If your physician intended to do a complete colonoscopy (the patient was prepped for a colonoscopy, he used a standard colonoscope and medicated the patient for a colonoscopy), and the documentation clearly states that he passed the splenic flexure, you may report a complete colonoscopy using 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]).

When the gastroenterologist passes the splenic flexure, CPT considers a colonoscopy complete, and you may report it as such, with no reduced- or discontinued-service modifiers.

If the physician does not pass the splenic flexure, however, the procedure is an incomplete colonoscopy.

Proper billing for an incomplete colonoscopy depends on the payer. For Medicare payers, you should:

- report 45378 for the colonoscopy
- attach modifier 53 (Discontinued procedure) to 45378 to describe a -partial- colonoscopy.

Section 15100B of the Medicare Carriers Manual specifically instructs, -An incomplete colonoscopy (e.g., the inability to extend beyond the splenic flexure) is billed and paid using colonoscopy code 45378 with modifier 53.-

In contrast, for payers that follow CPT guidelines, you should:

- report 45738
- append modifier 52 (Reduced services)
- include documentation.

If you are unsure whether your payer follows CPT or CMS guidelines, be sure to ask for clarification--preferably in writing.

Something to consider: If the physician intended to perform a sigmoidoscopy (in other words, he prepped the patient for a sigmoidoscopy with the intention of providing that service only), you would report 45330 (Sigmoidoscopy, flexible; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]) rather than an incomplete colonoscopy.