Flexible Sigmoidoscopy

A patient with diarrhea and history of ulcerative colitis post colectomy, ileo-anal pouch anastomosis, pouchitis and anastomotic stricture presents for flexible sigmoidoscopy. After anesthesia was provided, the sigmoidoscopy was initiated and all findings were normal. A Through-The-Scope (TTS) dilator was passed through the scope and dilation with a 10-11-12 mm colonic balloon dilator was performed. Our question is since the dilation was performed with no evidence of stricture, can we report CPT code 45340 , Sigmoidoscopy, flexible; with dilation by balloon, 1 or more strictures? ...

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Note:  The following article synopsis was NOT provided by the AHA. It was created by Find-A-Code/innoviHealth.

Article Overview

This premium article examines a flexible sigmoidoscopy scenario involving dilation performed during the examination and explains the coding question that arises when the endoscopic findings do not show a visible stricture. It is intended for coding professionals who need guidance on procedure reporting for lower endoscopy cases, especially when interpreting documentation of therapeutic intervention during the same session.

Why This Topic Matters

Accurate reporting of endoscopic procedures depends on matching the documented services with the correct procedure category. Articles like this help coders evaluate whether a therapeutic maneuver documented during flexible sigmoidoscopy supports reporting a dilation code.

What You Will Learn

  • How a flexible sigmoidoscopy with dilation is addressed for coding purposes.
  • How documentation of the performed service affects procedure reporting.
  • What considerations arise when dilation is performed despite normal endoscopic findings.
  • How to interpret a coding question involving lower endoscopy and therapeutic intervention.

Who Should Read This

  • Medical coders
  • Coding auditors
  • Revenue cycle professionals
  • Compliance staff
  • Clinical documentation improvement specialists

Codes Discussed


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