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Need help with incomplete colonoscopy and biopsy CPT code

Margaret Posted Fri 04th of March, 2011 18:40:26 PM

I am not quite sure how to code this scenario and need some help. Pt has Medicare.

Due to changes in bowel habits, pt was scheduled for a colonoscopy. Please see OP note.

The colonoscope was slowly advanced through the colon and beyond the level of the distal transverse/splenic flexure. The prep was suboptimal with a fair amount of stool. In the distal transverse colon, there was a small ulcerated lesion, which was biopsied with forceps biopsy and tattooed. After this was complete, we attempted to advance the scope more proximally into the colon.. Despite turning the pt on his side, on his back and with significant pressure on his abdomen, the colonoscopy could not be advanced beyond the hepatic flexure. The total time attempted for the colonoscopy was approx. 1 hour. Despite all our attempts, there was never any progress beyond the hepatic flexure. Of note, there appeared to be no significant loop within the colonoscope because at all points during the colonoscope, the scope moved in a one-to-one fashion. The colonoscope was slowly removed.

Since this is a medicare pt, would I bill 45378-53. what about the biopsy?

Thanks in advance for your help!

SuperCoder Answered Mon 07th of March, 2011 05:22:01 AM

I am not sure of 45378-53. Since there was reason for doing colonoscopy, i.e, change in bowel habits, and also there was a small ulcerated lesion in distal transverse colon which would make it "not a screening, but a diagnostic colonoscopy". Since the ulcer was biopsied, so I would go for 45380-53.

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