Hello, I need help with how to code for this OP note. The 2 cpt codes which are 45335 (Sigmoid flex inj) and 45331 (Sigmoid flex BX) but I need to know if I need to use modifier 53 and for what cpt code or for both? The OP note reads...
Several diverticula were seen in the distal descending colon and sigmoid colon
A circumferential mass with stigmata of recent bleeding of malignant appearance was found in the distal descending colon at 35 cm from the anus. The mass caused a partial obstruction. The scope could not traverse the lesion and the exam could not be finished. Multiple cold forceps biopsies were performed for histology. 5 ml spot injection was successfully applied for tattooing. Medium internal hemorrhoids were noted
Can I add modifier 53 since the exam could not be finished? and do I add the modifier 53 to both CPT codes?
Thank you in advance!
A circumferential mass with stigmata of recent bleeding of malignant appearance was found in the distal descending colon at 35 cm from the anus. The mass caused a partial obstruction. The scope could not traverse the lesion and the exam could not be finished. Multiple cold forceps biopsies were performed for histology. 5 ml spot injection was successfully applied for tattooing. Medium internal hemorrhoids were noted
Can I add modifier 53 since the exam could not be finished? and do I add the modifier 53 to both CPT codes?
Thank you in advance!