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 procedure documented. Code 45300 is not appropriate to report in addition because the dilation is part of the primary procedure described by 45303, making the additional reporting of a diagnostic proctosigmoidoscopy without mentioning dilation (45300) unnecessary and incorrect in this context.

Documentation States "Diagnostic Proctosigmoidoscopy Performed with Balloon Dilation