March 1, 2018

Question:
How do I report a diagnostic colonoscopy, if the prep is incomplete and the scope is able to be advanced past the splenic flexure, but does not get all the way to the cecum?

Answer:
Per CPT, if it is a diagnostic or screening colonoscopy, report, the diagnostic colonoscopy code (45378) with a 53 modifier.

*This response is based on the best information available as of 03/01/18.