General Surgery Coding Alert

Question: Our surgeon performed a diagnostic colonoscopy but was unable to get past the rectum due to a tight surgical colorectal anastomosis. The surgeon suggested that the patient would need surgery to correct the anastomosis. He also mentioned inadequate preparation for the procedure and discontinued the procedure. He then sent the patient to radiology for a barium enema examination. Can I bill the colonoscopy procedure that our surgeon attempted? If so, should I use the modifier 52 or 53?

Oklahoma Subscriber

Answer: No, you should not bill the procedure your surgeon attempted as a colonoscopy with either modifier 52 (Reduced services) or 53 (Discontinued procedure).

Instead, you should bill the service as a flex sigmoidoscopy, most likely 45330 (Sigmoidoscopy, flexible; diagnostic, including collection of specimen[s] by brushing or washing, when performed [separate procedure]) for the procedure you describe. If the surgeon had documented any other work, such as a biopsy, you would select the appropriate flex sigmoidoscopy code from the range 45330-45347.

Update: This answer is a change from what you may have learned before CPT^® overhauled the endoscopy codes in 2015. At that time, 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.