Question: Florida Subscriber Answer: Look at the intent of the procedure. 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]). -- Clinical and coding expertise for this issue provided by Michael Weinstein, MD, a gastroenterologist in Washington, D.C., and former member of the AMA's CPT Advisory Panel; and Linda Parks, MA, CPC, CMC, CMSCS, an independent coding consultant in Atlanta.
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 performed a snare polpyectomy during the colonoscopy; you should report 45385 ( ... with removal of tumor[s], polyp[s], or other lesion[s] by snare technique).