Coding Incomplete Colonoscopies

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December 3, 2015

Question:

Which code would be appropriate to report 45330, Sigmoidoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure) or 45378, Colonoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure), if the physician is unable to advance the colonoscope to the cecum?

Answer:

Per CPT guidelines, if the colonoscopy was a screening or diagnostic colonoscopy, CPT code 45378 would be reported with modifier 53, Discontinued Procedure. This indicates that a diagnostic or screening was not complete to the cecum. If the colonoscope does not reach the splenic flexure, a sigmoidoscopy, code 45330, would be reported.

If the colonoscopy was therapeutic and it is not complete to the cecum, the appropriate therapeutic colonoscopy code is reported with a 52 modifier.

Refer to the decision tree in the CPT Professional codebook.

*This response is based on the best information available as of 12/03/15.