Question

When performing a diagnostic or screening endoscopic procedure on a patient who is scheduled and prepared for a total colonoscopy, if the physician is unable to advance the colonoscope to the cecum or colon-small intestine anastomosis due to unforeseen circumstances, report 45378 (colonoscopy) or 44388 (colonoscopy through stoma) with modifier _____ and provide appropriate documentation.

a) -52
b) -74
c) -76
d) -79

Answer 1

For an incomplete colonoscopy, the appropriate code to use with a colonoscope is either 45378 or 44388 with modifier -53, along with necessary documentation.

Step-by-step explanation:

When performing a diagnostic or screening endoscopic procedure, such as a total colonoscopy, and the physician is unable to advance the colonoscope to the cecum or colon-small intestine anastomosis for unforeseen reasons, the correct code to use would be either 45378 for a colonoscopy, or 44388 for a colonoscopy through stoma, and it should be reported with modifier -53, not -52, -74, -76, nor -79. Modifier -53 indicates that the procedure was discontinued due to extenuating circumstances or those that threaten the well-being of the patient. It is also essential to include appropriate documentation to support the use of this modifier.