Gastroenterology Coding Alert

Question: Our gastroenterologist performed a diagnostic colonoscopy on a patient with regional enteritis in the small and large intestines, but the procedure ended at the distal transverse colon. Is that considered a complete colonoscopy?


Arizona Subscriber
Answer: Once the gastroenterologist gets past the splenic flexure, CPT considers a colonoscopy complete, so you can report it as such. On your claim, you should:
   report 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]) for the colonoscopy.
   attach ICD-9 code 555.2 (Regional enteritis; small intestine with large intestine) to 45378 to prove medical necessity for the procedure.

Exception: When a colonoscopy does not pass the splenic flexure, the procedure is an incomplete colonoscopy. When your gastroenterologist performs an incomplete colonoscopy, you should:
   report 45378 for the colonoscopy.
   attach modifier 52 (Reduced services) to 45378 to show that you are only reporting part of a colonoscopy.
   attach ICD-9 code 555.2 to 45378 to prove medical necessity for the procedure.