Gastroenterology Coding Alert

Question: A provider performs diagnostic colonoscopy. During the procedure, he is able to progress the colonoscope beyond the splenic flexure, but is not able to reach up to the cecum. How do we report this procedure?

Maine Subscriber

Answer: This is a diagnostic colonoscopy procedure. In this scenario, you may report 45378 (Colonoscopy, flexible; diagnostic, including collection of specimen[s] by brushing or washing, when performed [separate procedure]), and append modifier 53 (Discontinued procedure).

If the provider was not able to reach even the splenic flexure, you would report 45330.

Alternatively, if the provider was able to reach the cecum, you would report 45378.

Remember: You need not report 45378in conjunction with 45379 – 45393 (Colonoscopy, flexible;…), because flexible colonoscopy is already included in these codes, and 45379-45393 represent added interventions performed along with flexible colonoscopy.

Tip: For colonoscopy with decompression (in case of a pathologic distention), use45393 (Colonoscopy, flexible; with decompression [for pathologic distention][eg, volvulus, megacolon], including placement of decompression tube, when performed).