Documentation states "Diagnostic proctosigmoidoscopy performed with balloon dilation." CPT codes available to report these procedures are:
45300 - Proctosigmoidoscopy, rigid; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure)
45303 - Proctosigmoidoscopy, rigid; with dilation (e.g. balloon, guide wire, bougie)
How would the coder accurately report these procedures?

Question

Quizplus · Accepted Answer

The correct code is 45303 because it specifically describes a proctosigmoidoscopy with dilation, which matches the documentation. Code 45300 is not used because the dilation aspect is integral to the procedure described, making 45303 the more accurate and specific code. Modifier -59 or -51 is not needed as only one procedure code is being reported.

Documentation States "Diagnostic Proctosigmoidoscopy Performed with Balloon Dilation