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Screening Colonoscopy Leads To Open Procedure

Kirsten Posted Tue 24th of November, 2015 13:38:41 PM

A patient presents for a screening colonoscopy. She had no personal or family history of colon cancer or polyps and denies any abdominal pain or GI symptoms. Once the scope went past the rectum into the sigmoid colon, a foreign body was noted. It was a toothpick that was wedged tight in the colon. The Doc attempted removal, but it would not budge. He then concluded that it could not be removed endoscopically due to possible perforation. The procedure was discontinued and the patient had a partial colectomy performed a few hours later. How should this be coded? I know that you can code a diagnostic colonoscopy if it leads to an open procedure, or if the decision is made to perform an open procedure after a diagnostic colonoscopy. Does this still hold true if the colonoscopy was a screening instead of diagnostic? If so, should I append a 58 modifier to the colonoscopy, in addition to a modifier 53, or does the 58 modifier go on the colectomy CPT code? Please advise.

SuperCoder Answered Wed 25th of November, 2015 04:58:37 AM

Thanks for your question.

If an endoscopic procedure is converted to an open procedure, only the open procedure may be reported. Neither a surgical endoscopy nor a diagnostic endoscopy code should be reported with the open procedure code when an endoscopic procedure is converted to an open procedure.

If a diagnostic endoscopy is the basis for and precedes an open procedure, the diagnostic endoscopy is separately reportable with modifier 58. However, the medical record must document the medical reasonableness and necessity for the diagnostic endoscopy.

Kirsten Posted Mon 30th of November, 2015 14:44:19 PM

I apologize for the apparent confusion. A screening colonoscopy was performed at an ambulatory surgical center. During the screening colonoscopy, a foreign body was found in the sigmoid colon, (which later turned out to be a chicken bone). After seeing the foreign body during her screening colonoscopy, the patient was discharged from the Surgery Center and was instructed to go to the Hospital and was admitted to the Inpatient Hospital facility the same day for an urgent colon resection due to foreign body. The patient denied any personal or family history of GI issues, and patient reported no symptoms of GI distress (bleeding, abdominal pain, etc...) when she had her screening colonoscopy done at the Surgery Center. My question is: Can we code her screening colonoscopy at the Surgery Center? If so, would it be a G0121 with a modifier 58? Even though the colonoscopy was performed at a different place of service than the colon resection? This was not a scope procedure turned open. These procedures were performed at 2 different places of service on the same day by the same surgeon. Please advise.

Kirsten Posted Mon 30th of November, 2015 14:55:52 PM

In addition, the screening colonoscopy was terminated after spotting the foreign body in the sigmoid colon. So a 53 modifier should be reported as well? In addition to a modifier 58? If so, in what order should the modifiers be reported? 53 or 58 first?

SuperCoder Answered Tue 01st of December, 2015 02:33:33 AM


Yes, we can code screening colonoscopy G0121 with modifier 73 for ambulatory surgical center.

And for the inpatient hospital, you can use open procedure for foreign body removal.

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