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2015 CPT Book - New definition for Colonoscopy procedures


The definition of a colonoscopy examination is now specifically described in CPT as the examination of the entire colon, from the rectum to the cecum or colon-small intestine anastomosis, and may include examination of the terminal ileum or small intestine proximal to an anastomosis.

When performing a diagnostic or screening 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 53 and provide appropriate documentation.

If a therapeutic examination colonoscopy is performed and does not reach the cecum or colon-small intestine anastomosis, report the appropriate therapeutic colonoscopy code with modifier 52 and provide appropriate documentation.

New codes for the colonoscopy family include endoscopic mucosal resection (EMR), band ligation and decompression for pathologic distention. Revised codes address appropriate reporting of ablation and stent placement. 

Colonoscopy through Stoma

Colonoscopy through stoma has been specifically defined in CPT as the examination of the colon, from the colostomy stoma to the cecum or colon-small intestine anastomosis, and may include examination of the terminal ileum or small intestine proximal to an anastomosis. 

When performing a diagnostic or screening colonoscopy through stoma 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 44388 with modifier 53 and provide appropriate documentation.

If a therapeutic colonoscopy is performed and does not reach the cecum or colon-small intestine anastomosis, report the appropriate therapeutic colonoscopy through stoma code with modifier 52 and provide appropriate documentation.

New codes for the colonoscopy through stoma family include endoscopic mucosal resection, submucosal injection, balloon dilation, EUS, EUS with FNA, and decompression for pathologic distention. Revised codes address appropriate reporting of ablation and stent placement. 

Enteroscopy

A new definition and instructions for reporting antegrade transoral small intestine endoscopy (i.e., enteroscopy) have been added to the section guidelines. Enteroscopy is defined by the most distal segment of small intestine that is examined; coding does not reflect the technology used to perform the examination.

Codes in the 44360 family for enteroscopy, not including ileum (44360–44373), are endoscopic procedures to visualize the esophagus through the jejunum using an antegrade approach. Codes in the 44376 family for enteroscopy, including ileum (44376–44379), are endoscopic procedures to visualize the esophagus through the ileum using an antegrade approach. 

If an endoscope cannot be advanced at least 50 cm beyond the pylorus, see the appropriate code in the EGD family (43233, 43235–43259, 43266, 43270). If an endoscope can be passed at least 50 cm beyond pylorus, but only into jejunum, see the appropriate code in the enteroscopy, not including ileum family (44360–44373). 

To report retrograde examination of small intestine via anus or colon stoma, use 44799, Unlisted procedure, small intestine.

There were no changes to the language of the individual CPT codes.

Unlisted Procedures

A new code has been developed and one revised to distinguish unlisted procedure of the colon from unlisted procedure of the small intestine and unlisted procedure of the rectum.

See also complete list of 2015 CPT Changes

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