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Kirsten Posted Wed 08th of July, 2015 15:16:42 PM

The patient had an existing colostomy and mucous fistula at the level of the sigmoid colon. The procedure was SUPPOSED to be a sigmoidoscopy from the anus to see if conditions were right for a colostomy takedown. Instead, scope would only advance to the rectum where there was a complete rectal occlusion due to thick mucous. The Doc then placed a scope into the mucous fistula to see a retro view the distal sigmoid, rectum and anus. However, the rectum was completely occluded by mucous this way as well. Would the appropriate code(s) be 45330-53 for the anal approach, and 45330-XS for the retro scope via mucous fistula? He did not utilize the scope at all in the sigmoid stoma. I appreciate your assistance with this complicated procedure(s).

SuperCoder Answered Thu 09th of July, 2015 03:13:16 AM

Well, CPT 45330 with modifier 53 seems appropriate. Because the scope was not utilized to examine the sigmoid colon through both the approaches. Which finally stand to discontinued procedure. Modifier XS defines a subset of the modifier 59 (Distinct Procedural Service) will not go as this is append to identify a distinct service when the provider performs services on a patient on different organs or structures, which is not performed here. Hope it helps!

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