Gastroenterology Coding Alert

Question: The provider attempted to perform a diagnostic colonoscopy for a patient. However, he felt that the patient was inadequately prepared for the procedure, and he could not get the scope to go beyond the rectum as he found a tight surgical colorectal anastomosis. The provider discontinued the procedure and suggested that the patient would need surgery to correct the anastomosis. How do we code this scenario?

Maine Subscriber

Answer: Although your provider began with an intent to do a colonoscopy, you would actually report this as a flex sigmoidoscopy, most likely 45330 (Sigmoidoscopy, flexible; diagnostic, including collection of specimen[s] by brushing or washing, when performed [separate procedure]). If your provider had documented any other work, such as a biopsy, you would select the appropriate flex sigmoidoscopy code from the range (45330-45347).

Do not think of reporting this service as a colonoscopy with modifier 52 (Reduced services) or 53 (Discontinued procedure).

Here’s why: Beginning 2015, CPT^® added the instruction, “Report flexible sigmoidoscopy (45330-45347) for endoscopic examination during which the endoscope is not advanced beyond the splenic flexure.” Since the 2015 changes, you should also be following other specific instructions about when to use modifiers 52 or 53 for diagnostic, screening, or therapeutic colonoscopies that advance past the splenic flexure, but do not reach the cecum or colon-small intestine anastomosis.

Coding tip: The CPT^® introductory notes for the Colon and Rectum Endoscopy section provides a “Colonoscopy Decision Tree” that provides very clear direction about how to code colonoscopy services based on the purpose of the test and how far the scope advances. You should familiarize yourself with this tool to make sure you’re up to date on coding rules for these procedures.