Part B Insider (Multispecialty) Coding Alert

Question: My doctor did an incomplete colonoscopy and I’m not sure how to code it. See following which are findings from his report: A fungating circumferential bleeding mass of malignant appearance was found in the proximal rectum and distal sigmoid colon at 15 cm from the anus. The mass caused a partial obstruction. The scope could not traverse the lesion and the exam could not be finished. Cold forceps biopsies were performed. 4 1 ml india ink injections were successfully applied for tattooing. He coded colon w/biopsy and colon w/tattoo injection but I’m not sure if that’s correct. Can I bill both with incomplete modifier or should I bill flexible sigmoidoscopy with biopsy and injection?

Answer: You will have to report the procedure on what the original intention of your clinician was. If he intended to perform a colonoscopy and was unable to complete it, then you report the appropriate colonoscopy codes with modifiers attached to it.

Since your clinician performed biopsy and tattooing of the mass, your clinician would be right in the way he reported the procedures. You should report 45380 (Colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiple) for the biopsy and 45381 (Colonoscopy, flexible, proximal to splenic flexure; with directed submucosal injection(s), any substance) for the tattooing procedure performed.

Append the modifier 52 (Reduced services) to these CPT^® codes to let the payer know that your clinician intended to perform a colonoscopy but could not do so because the mass caused obstruction that did not allow further passage of the scope.

If on the other hand, if the intention of your clinician was to perform a sigmoidoscopy, then you report the procedures using appropriate flexible sigmoidoscopy procedural codes which in this case scenario would be 45331 (Sigmoidoscopy, flexible; with biopsy, single or multiple) and 45335 (Sigmoidoscopy, flexible; with directed submucosal injection[s], any substance). Again, use the modifier 52 with these codes.