Question: A patient who underwent a total colectomy and retained a rectal stump came to our office. Our gastroenterologist conducted a flexible sigmoidoscopy with biopsy using a colonoscope. How should I code this procedure? Is it appropriate to report a colonoscopy code or a sigmoidoscopy code?
Pennsylvania Subscriber
Answer: Even though the provider utilized a colonoscope (which is flexible rather than rigid) instead of a proctosigmoidoscope, you cannot report a colonoscopy code. This is because the entire colon was not examined.
Based on the information provided, the patient had previously undergone a total colectomy. In this case, the gastroenterologist performed a visualization of the rectal stump along with a biopsy. As a result, the most suitable CPT® code for this situation is 45331 (Sigmoidoscopy, flexible; with biopsy, single or multiple), despite the use of a colonoscope. Additionally, you should attach modifier 52 (Reduced services) to the procedure code, as the physician examined the anus and rectum but not the sigmoid, which had been surgically removed.
