Wiki Colonoscopy aborted prior to scope insertion

[AthensCoder]

Hello Fellow Coders,

I have come across a very unique situation. Our provider had to abort a screening colonoscopy prior to scope insertion. Operative report reads as follows:

Digital rectal exam was abnormal. Procedure was aborted prior to scope insertion after sedation due to poor prep on digital rectal exam.

Normally I would code 45330 if the scope didn't reach past the sigmoid colon, however in this case, the scope wasn't even inserted. So it's throwing me off.

How would you code? Please help.

 

[TThivierge]

Hi Sonja
Check out modifier 53 to add to CPT code. Also when provider comes back he should add this in his document (redoing it) and add modifier 76.
I hope this data helps you
Lady T