© Copyright 2025 American Medical Association. All rights reserved.
A rigid proctosigmoidoscopy is a diagnostic and therapeutic procedure that involves the examination of the rectum and the lower part of the colon (sigmoid colon) using a rigid scope. This procedure is specifically designed for the removal of a single tumor, polyp, or other lesion utilizing a snare technique. The snare technique involves the use of a wire loop that is placed around the lesion, which is then heated to excise and cauterize the tissue simultaneously. This method is particularly effective for lesions that are accessible and can be removed in a single piece or in a piecemeal fashion, depending on the size and nature of the lesion. The procedure begins with the insertion of an obturator into the scope, which is then introduced into the anus and advanced into the rectum. Air insufflation is used to expand the rectal walls, allowing for better visualization of the mucosal surface. Once the lesion is identified, the snare is employed to remove it, ensuring that any bleeding is controlled through cauterization. This procedure is essential for both diagnostic purposes and for the treatment of conditions such as polyps, which may have the potential to develop into colorectal cancer if left untreated.
© Copyright 2025 Coding Ahead. All rights reserved.
The procedure is indicated for the following conditions:
The procedure involves several key steps to ensure effective examination and removal of the lesion:
Post-procedure care involves monitoring the patient for any immediate complications such as bleeding or perforation. Patients may experience some discomfort or cramping following the procedure, which is typically manageable. Instructions for follow-up care, including signs of complications to watch for, should be provided. Additionally, the patient may be advised on dietary modifications or restrictions following the procedure to promote healing and recovery.
| Short Descr | PROCTOSIGMOIDOSCOPY REMOVAL | Medium Descr | PROCTOSGMDSC RIGID RMVL 1 LESION SNARE TQ | Long Descr | Proctosigmoidoscopy, rigid; with removal of single tumor, polyp, or other lesion by snare technique | 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 | Surgical procedure on ASC list in CY 2007; 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 |
| 22 | Increased procedural services: when the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. documentation must support the substantial additional work and the reason for the additional work (ie, increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required). note: this modifier should not be appended to an e/m service. | 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). | 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. | GC | This service has been performed in part by a resident under the direction of a teaching physician | PT | Colorectal cancer screening test; converted to diagnostic test or other procedure |
|
Date
|
Action
|
Notes
|
|---|---|---|
| 2017-01-01 | Changed | Moderate (Conscious) Sedation flag removed. See new Moderate Sedation category. |
| 1994-01-01 | Added | First appearance in code book in 1994. |
Get instant expert-level medical coding assistance.