Gastroenterology Coding Alert

Question: The provider performed a colonoscopy for removal of a foreign body within the colon. However, he could not reach the cecum or colon. How do we report this procedure? Do they allow us to report use of fluoroscopy in this procedure, just in case?

Utah Subscriber

Answer: The correct CPT^® code for this procedure is 45379 (Colonoscopy, flexible; with removal of foreign body[s]). However, if the provider could not access the cecum or reach the small intestine, you will need to append modifier 52 (Reduced services).

For other similar codes 45380- 44398 (Colonoscopy, flexible; …) you may apply the same rule.

Remember: The AMA guidelines tell you not to report 45379 with 45378 (Colonoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure). Also, in case you used fluoroscopy, use 76000 (Fluoroscopy [separate procedure], up to 1 hour physician or other than 71023 or 71034 [eg, cardiac fluoroscopy]).