Eleen Posted Tue 18th of September, 2012 13:49:15 PM
Abdominal pain/distention, colonic decompression
The Colonoscope was introduced through the anus and advanced to the ascending colon for evaluation. This was the intended extent. The colonoscopy was performed without difficulty. The patient tolerated the procedure well.
Procedure:The Colon The perianal and digital rectal examinations were normal.
Findings: Edematous rectum. Areas of ulceration found in proximal and rectosigmoid colon. Possible polyp or mass in sigmoid colon which did not completely obstruct as scope was able to be traversed passed area.
Decompression of the colon was attempted and was successful, with complete decompression achieved. Following the
maneuver, a tube was placed to maintain the decompression.
Transverse Colon Hepatic Flexure
-Possible polyp or mass in sigmoid colon which did not completely obstruct as scope was able to be aversed passed area.
-Areas of ulceration found in proximal colon and rectosigmoid.
-Colonic decompression tube left in place
We code 45378 and ?
SuperCoder Answered Tue 18th of September, 2012 14:24:13 PM
Colonic decompression is part of the CPT description of a colonoscopy (45378, colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen[s] by brushing or washing, with or with colon decompression [separate procedure]) and is not separately billable.
The phrase "separate procedure" may be confusing. Procedures or services that are considered an integral component of a total service or procedure are indicated by this phrase. "The codes designated as 'separate procedure' should not be reported in addition to the code for the total procedure or service of which it is considered an integral component," the CPT states.
While there are new CPT codes for colonic stent placement, there are no specific codes for tube placement or the use of a guide wire in the colon.Your only option is to use unlisted-procedure code 44799 (unlisted procedure, intestine) to report the guide-wire. Whenever you use an unlisted code, you must include an operative report and a separate statement describing the steps taken in the guide wire procedure. This separate report should include the typical time taken to complete the procedure and mention a listed service that is its closest equivalent.
For the fluoroscopic guidance, use code 76000 (fluoroscopy [separate procedure], up to one hour physician time) or 76001 (fluoroscopy, physician time more than one hour).