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A flexible sigmoidoscopy is a diagnostic procedure that allows for the examination of the sigmoid colon, which is the lower part of the large intestine. This procedure is performed using a flexible sigmoidoscope, a long, thin tube equipped with a light and camera, which is inserted through the anus and advanced through the rectum into the sigmoid colon. The primary purpose of this procedure is to identify and treat strictures, which are narrowings of the colon that can occur due to various factors such as previous surgeries, radiation therapy, or inflammatory diseases affecting the intestine. During the procedure, a transendoscopic balloon dilation technique is employed to widen the narrowed area of the colon. This involves the use of a specialized balloon device that is inserted through the sigmoidoscope and inflated at the site of the stricture. The inflation of the balloon is carefully monitored using a pressure gauge to ensure that it reaches the optimal level for effective dilation. After a brief period of inflation, the balloon is deflated and removed, allowing for a thorough inspection of the treated area to confirm the success of the dilation and to check for any potential injuries to the colon. This procedure is essential for alleviating symptoms associated with strictures and improving the overall function of the bowel.
© Copyright 2025 Coding Ahead. All rights reserved.
The flexible sigmoidoscopy with transendoscopic balloon dilation is indicated for the following conditions:
The procedure begins with the patient positioned appropriately to facilitate access to the rectum. A standard flexible sigmoidoscope is then introduced into the anus and carefully advanced through the rectum into the sigmoid colon. Once the sigmoidoscope is in place, the physician identifies the narrowed area of the colon, known as the stricture. To perform the dilation, a deflated balloon catheter is advanced through the instrument channel of the sigmoidoscope until it reaches the midpoint of the stricture. The balloon is then inflated while monitoring the pressure using a gauge to ensure that the inflation is optimal for effective dilation. The balloon remains inflated for a short duration, typically between 30 seconds to 2 minutes, to allow for adequate widening of the stricture. After the inflation period, the balloon is deflated and carefully removed from the colon. Following the dilation, the physician inspects the area of the stricture using the sigmoidoscope to confirm that the dilation has been successful and to check for any potential injuries to the colon that may have occurred during the procedure.
After the procedure, patients may be monitored for a short period to ensure there are no immediate complications. It is common for patients to experience mild discomfort or cramping following the dilation. The physician may provide specific post-procedure care instructions, including dietary recommendations and activity restrictions. Patients should be advised to report any unusual symptoms, such as severe pain, bleeding, or fever, to their healthcare provider. Follow-up appointments may be scheduled to assess the effectiveness of the dilation and to monitor the condition of the colon.
| Short Descr | SIG W/TNDSC BALLOON DILATION | Medium Descr | SIGMOIDOSCOPY FLX TNDSC BALO DILAT | Long Descr | Sigmoidoscopy, flexible; with transendoscopic balloon dilation | 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 | 45330 Sigmoidoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (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) | P8I - Endoscopy - other | 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). | 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. | 52 | Reduced services: under certain circumstances a service or procedure is partially reduced or eliminated at the discretion of the physician or other qualified health care professional. under these circumstances the service provided can be identified by its usual procedure number and the addition of modifier 52, signifying that the service is reduced. this provides a means of reporting reduced services without disturbing the identification of the basic service. note: for hospital outpatient 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). | 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. | 74 | Discontinued out-patient hospital/ambulatory surgery center (asc) procedure after administration of anesthesia: due to extenuating circumstances or those that threaten the well being of the patient, the physician may terminate a surgical or diagnostic procedure after the administration of anesthesia (local, regional block(s), general) or after the procedure was started (incision made, intubation started, scope inserted, etc). under these circumstances, the procedure started but terminated can be reported by its usual procedure number and the addition of modifier 74. note: the elective cancellation of a service prior to the administration of anesthesia and/or surgical preparation of the patient should not be reported. for physician reporting of a discontinued procedure, see modifier 53. | 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.) | AQ | Physician providing a service in an unlisted health professional shortage area (hpsa) | CR | Catastrophe/disaster related | GA | Waiver of liability statement issued as required by payer policy, individual case | GC | This service has been performed in part by a resident under the direction of a teaching physician | GW | Service not related to the hospice patient's terminal condition | PT | Colorectal cancer screening test; converted to diagnostic test or other procedure | Q6 | Service furnished under a fee-for-time compensation arrangement by a substitute physician or by a substitute physical therapist furnishing outpatient physical therapy services in a health professional shortage area, a medically underserved area, or a rural area | SG | Ambulatory surgical center (asc) facility service | X4 | Episodic/focused services: for reporting services by clinicians who provide focused care on particular types of treatment limited to a defined period and circumstance; the patient has a problem, acute or chronic, that will be treated with surgery, radiation, or some other type of generally time-limited intervention; reporting clinician service examples include but are not limited to, the orthopedic surgeon performing a knee replacement and seeing the patient through the postoperative period | 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. |
| 2015-01-01 | Changed | Description Changed |
| 2003-01-01 | Added | First appearance in code book in 2003. |
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