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A flexible sigmoidoscopy is a medical procedure that involves the use of a flexible tube equipped with a light and camera, known as a sigmoidoscope, to examine the lower part of the colon, specifically the sigmoid colon. This procedure is performed to identify and treat abnormalities such as tumors, polyps, or other lesions within the rectum and sigmoid colon. During the procedure, the sigmoidoscope is inserted through the anus and advanced through the rectum into the sigmoid colon. Air is insufflated to expand the colon, allowing for a clearer view of the mucosal lining. Once the scope is in place, the physician carefully inspects the mucosa for any lesions that may require treatment. If any tumors, polyps, or lesions are identified, ablation techniques are employed to destroy these abnormal growths. This may involve the use of a laser device, which is delivered through the endoscope to precisely target and ablate the lesions. The procedure also includes pre- and post-dilation steps, which may involve the use of guide wires and balloon catheters to facilitate access to the lesions. The goal of this procedure is to effectively remove or destroy the identified lesions while minimizing any potential complications or injuries to the surrounding tissue.
© Copyright 2025 Coding Ahead. All rights reserved.
The flexible sigmoidoscopy with ablation is indicated for the following conditions:
The procedure begins with the patient positioned appropriately to allow for the insertion of the sigmoidoscope. The physician then gently introduces the flexible sigmoidoscope into the anus and advances it through the rectum into the sigmoid colon. During this process, air is insufflated to separate the mucosal folds, providing a clearer view of the colon's interior. Once the sigmoidoscope is in place, the physician withdraws the scope slightly to inspect the mucosa thoroughly for any tumors, polyps, or lesions that may require treatment. Upon identifying the site of the lesion(s), if dilation is necessary to facilitate access for the ablation, a guidewire is inserted through the scope. Following this, a series of rigid tubes of increasing diameter are passed over the guidewire to dilate the lumen of the large intestine as needed. Alternatively, a balloon catheter may be advanced to the site of any stricture and inflated to widen the narrowed area. After dilation, the balloon catheter is removed, and a laser device is introduced through the endoscope to the distal margin of the most distal lesion. The physician then ablates the lesion as the endoscope is retracted, ensuring that the entire lesion is destroyed as the laser traverses it in a distal to proximal direction. This ablation process is repeated for all identified lesions. If further dilation is required after the lesions have been destroyed, it is performed again. Finally, the colon is re-examined using the endoscope to confirm that all lesions have been effectively ablated and to check for any injuries resulting from the procedure.
After the procedure, patients are typically monitored for any immediate complications. It is essential to assess the patient for signs of bleeding or perforation, which are potential risks associated with the procedure. Patients may experience some discomfort or cramping following the procedure due to air insufflation and manipulation of the colon. Instructions for post-procedure care will be provided, which may include dietary recommendations and activity restrictions. Follow-up appointments may be scheduled to monitor the patient's recovery and to discuss any further treatment options if necessary.
| Short Descr | SIGMOIDOSCOPY W/ABLATION | Medium Descr | SIGMOIDOSCOPY FLX ABLATION TUMOR POLYP/OTH LES | Long Descr | Sigmoidoscopy, flexible; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre- and post-dilation and guide wire passage, when performed) | 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 | Non office-based surgical procedure added in CY 2008 or later; payment based on OPPS relative payment weight. | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P8C - Endoscopy - sigmoidoscopy | MUE | 1 |
| 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.) | 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). | 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). | 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.) | AG | Primary physician | 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 | GZ | Item or service expected to be denied as not reasonable and necessary | 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 | 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 | Added | Added |
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