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A flexible colonoscopy is a diagnostic and therapeutic procedure that involves the use of a flexible tube equipped with a camera, known as a colonoscope, to visualize the interior of the colon. This procedure is specifically enhanced by the technique of transendoscopic balloon dilation, which is employed to treat strictures—narrowed areas within the colon that can impede the passage of stool and lead to various complications. Strictures may arise due to several factors, including previous surgical interventions, radiation therapy, or inflammatory diseases affecting the intestinal tract. During the procedure, the colonoscope is carefully inserted into the rectum and navigated through the colon to locate the stricture. Once identified, a specialized balloon device is introduced through the colonoscope's instrument channel and positioned at the site of the stricture. The balloon is then inflated to widen the narrowed segment of the colon, with careful monitoring of the inflation pressure to ensure optimal dilation. After the balloon is inflated for a brief period, it is deflated and removed. If multiple strictures are present, the procedure is repeated for each site, ensuring thorough treatment. Following the dilation, the physician inspects the treated areas to confirm the success of the dilation and to check for any potential injuries to the colon, thereby ensuring patient safety and procedural efficacy.
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The flexible colonoscopy with transendoscopic balloon dilation is indicated for the treatment of strictures within the colon. These strictures may result from various underlying conditions, including:
The procedure begins with the patient being positioned appropriately, typically in a left lateral position, to facilitate access to the colon. The physician then prepares the colon by ensuring it is adequately cleansed, often requiring a bowel prep prior to the procedure. Once the patient is ready, the flexible colonoscope is gently inserted into the rectum. The colonoscope is advanced through the rectum and into the colon, allowing the physician to visualize the entire colon on a monitor. As the scope is navigated, the physician identifies the location of the stricture. Upon locating the narrowed area, a balloon catheter is introduced through the instrument channel of the colonoscope. The catheter is carefully advanced to the center of the stricture. Once in position, the balloon is inflated using a pressure gauge to monitor the inflation level, ensuring it is optimal for dilation without causing injury to the surrounding tissue. The balloon remains inflated for a short duration to effectively widen the stricture. After the inflation period, the balloon is deflated and removed from the colon. If multiple strictures are identified, the colonoscope and balloon catheter are repositioned to the next stricture, and the dilation process is repeated. After addressing all strictures, the physician conducts a thorough inspection of each treated area to confirm successful dilation and to check for any potential complications, such as perforation or bleeding.
Post-procedure care involves monitoring the patient for any immediate complications, such as bleeding or perforation, which are rare but possible. Patients are typically observed in a recovery area until the effects of sedation have worn off. It is common for patients to experience mild cramping or discomfort following the procedure, which usually resolves quickly. Instructions for post-procedure care may include dietary recommendations, such as starting with clear liquids and gradually advancing to a regular diet as tolerated. Patients are advised to report any severe abdominal pain, persistent bleeding, or other concerning symptoms to their healthcare provider. Follow-up appointments may be scheduled to assess the effectiveness of the dilation and to monitor for any recurrence of strictures.
| Short Descr | COLONOSCOPY W/BALLOON DILAT | Medium Descr | COLSC FLEXIBLE W/TRANSENDOSCOPIC BALLOON DILAT | Long Descr | Colonoscopy, 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 | 45378 Colonoscopy, 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) | P8D - Endoscopy - colonoscopy | MUE | 1 | CCS Clinical Classification | 76 - Colonoscopy and biopsy |
| PT | Colorectal cancer screening test; converted to diagnostic test or other procedure | 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.) | AG | Primary physician | 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 | GZ | Item or service expected to be denied as not reasonable and necessary | KX | Requirements specified in the medical policy have been met | 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 | Changed | Description Changed |
| 2013-01-01 | Changed | Medium Descriptor changed. |
| 2003-01-01 | Added | First appearance in code book in 2003. |
| 1984-12-31 | Deleted | Code deleted. |
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