AHA Coding Clinic® for HCPCS - 2011 Issue 3; ASK the EDITOR

Lower balloon-assisted enteroscopy with fluoroscopy

A patient presents for lower balloon-assisted enteroscopy with fluoroscopy. The enteroscopy was introduced through the anus and advanced to the mid ileum. Approximately 75 to 100 cm of the ileum was examined and the most proximal region was successfully injected with 10 mL of India ink for tattooing. What is the appropriate CPT code for the lower balloon-assisted enteroscopy with India ink tattooing performed under fluoroscopic guidance? Also, should a modifier be appended since the entire ileum was not examined? ...

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