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A rigid proctosigmoidoscopy is a diagnostic and therapeutic procedure that involves the examination of the rectum and sigmoid colon using a rigid scope. This procedure is specifically performed with the addition of dilation techniques to address strictures, which are narrowings of the rectal or sigmoid colon lumen. Strictures can arise from various underlying conditions, including complications from previous surgeries, radiation therapy, or inflammatory diseases affecting the intestines. During the procedure, an obturator is first inserted into the scope, which is then introduced into the anus and advanced approximately 5 centimeters into the rectum. After the obturator is removed, the eyepiece is attached to allow for direct visualization. The scope is carefully advanced to the site of the stricture, utilizing air insufflation to separate the mucosal folds for better visibility. A guidewire is then introduced under direct visualization, positioned just proximal to the stricture. Following this, a balloon catheter is passed over the guidewire and placed within the stricture. The balloon is inflated to dilate the narrowed area, held in place for a brief period, and subsequently deflated and removed. Alternatively, a bougie, which is a flexible cylindrical instrument, may be employed to stretch the stricture. After dilation, the area is thoroughly inspected with the scope to confirm the success of the dilation and to check for any potential injuries to the rectum or sigmoid colon that may have occurred during the procedure.
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The procedure of rigid proctosigmoidoscopy with dilation is indicated for the following conditions:
The procedure of rigid proctosigmoidoscopy with dilation involves several key steps:
Post-procedure care following a rigid proctosigmoidoscopy with dilation typically involves monitoring the patient for any immediate complications. Patients may experience some discomfort or cramping following the procedure, which is generally mild and self-limiting. It is important to provide instructions regarding signs of potential complications, such as excessive bleeding, severe pain, or signs of infection. Follow-up appointments may be necessary to assess the success of the dilation and to monitor for any recurrence of strictures. Patients should be advised to maintain communication with their healthcare provider regarding any concerns or unusual symptoms that may arise after the procedure.
| Short Descr | PROCTOSIGMOIDOSCOPY DILATE | Medium Descr | PROCTOSGMDSC RIGID W/DILATION | Long Descr | Proctosigmoidoscopy, rigid; with dilation (eg, balloon, guide wire, bougie) | Status Code | Active Code | Global Days | 000 - Endoscopic or Minor Procedure | PC/TC Indicator (26, TC) | 0 - Physician Service Code | Multiple Procedures (51) | 3 - Special payment adjustment rules for multiple endoscopic procedures apply. | Bilateral Surgery (50) | 0 - 150% payment adjustment for bilateral procedures does NOT apply. | Physician Supervisions | 09 - Concept does not apply. | Assistant Surgeon (80, 82) | 1 - Statutory payment restriction for assistants at surgery applies to this procedure... | Co-Surgeons (62) | 0 - Co-surgeons not permitted for this procedure. | Team Surgery (66) | 0 - Team surgeons not permitted for this procedure. | Endoscopic Base Code | 45300 Proctosigmoidoscopy, rigid; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure) | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | Procedure or Service, Multiple Reduction Applies | ASC Payment Indicator | Office-based surgical procedure added to ASC list in CY 2008 or later with MPFS nonfacility PE RVUs; payment based on OPPS relative payment weight. | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P8C - Endoscopy - sigmoidoscopy | MUE | 1 | CCS Clinical Classification | 77 - Proctoscopy and anorectal biopsy |
| 51 | Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d). | 53 | Discontinued procedure: under certain circumstances, the physician or other qualified health care professional may elect to terminate a surgical or diagnostic procedure. due to extenuating circumstances or those that threaten the well being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued. this circumstance may be reported by adding modifier 53 to the code reported by the individual for the discontinued procedure. note: this modifier is not used to report the elective cancellation of a procedure prior to the patient's anesthesia induction and/or surgical preparation in the operating suite. for outpatient hospital/ambulatory surgery center (asc) reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use). | 58 | Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period: it may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. this circumstance may be reported by adding modifier 58 to the staged or related procedure. note: for treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78. | 59 | Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25. | 78 | Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period: it may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). when this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure. (for repeat procedures, see modifier 76.) | 79 | Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, see modifier 76.) | GC | This service has been performed in part by a resident under the direction of a teaching physician | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure | XU | Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service |
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| 2017-01-01 | Changed | Moderate (Conscious) Sedation flag removed. See new Moderate Sedation category. |
| 2002-01-01 | Changed | Code description changed. |
| Pre-1990 | Added | Code added. |
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