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Flex sig on patient who only has rectal stump

Robyn Posted Fri 29th of May, 2015 11:13:25 AM

Patient had total colectomy & still has rectal stump. Physician performed flex sig w/biopsy & I'm wondering if this can be billed as a flex sig since patient only has rectal stump?

SuperCoder Answered Mon 01st of June, 2015 03:38:16 AM

You can use CPT code 45305 with 52 modifier for reduced services since provider examines the inner part of the anus and rectum without sigmoid colon using a proctosigmoidoscope.

Robyn Posted Mon 01st of June, 2015 13:00:26 PM

the provider did not use a proctosigmoidoscope, he used a colonoscope which is flexible, not rigid.

SuperCoder Answered Tue 02nd of June, 2015 03:03:39 AM

We cannot take code from colonoscopy series since colonoscopy was not performed due to absence of the entire colon. The patient has a history of total colectomy performed. What was performed was visualization of the rectal stump with biopsy. Even though the provider used a colonoscope, the most appropriate CPT code that can be used in this scenario is 45305 with 52 modifier.

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