Mountain State Medical Policy Bulletin
Section: Surgery
Number: S-90
Topic: Failed or Incomplete Colonoscopy
Effective Date: August 1, 2005
Issued Date: August 1, 2005
Date Last Reviewed: 06/2005

General Policy Guidelines

Indications and Limitations of Coverage

A colonoscopy which does not extend beyond the splenic flexure should be reported under the sigmoidoscopy codes 45330-45345, as appropriate.

In addition, when any of the following indications are applicable, an additional 50% of the allowance for the appropriate code (45330-45345) can be made:

  • Prior barium enema suspicious of abnormality in the descending colon (tumor, diverticulitis, etc.).
  • Determining the extent of disease in "distal mucosal" ulcerative colon.
  • Follow-up of a post subtotal colectomy patient (carcinoma in colon) with anastomosis in the descending colon.
  • Attempted full colonoscopy that is incomplete due to adhesions, etc. making it impossible to go beyond the splenic flexure.

Payment for indications other than those listed above should be made in accordance with established allowances under codes 45330-45345.

Procedure Codes

453304533145332453334533445335
453374533845339453404534145342
45345     

Traditional Guidelines

Refer to General Policy Guidelines

FEP Guidelines

Refer to General Policy Guidelines

PPO Guidelines

Refer to General Policy Guidelines

Managed Care POS Guidelines

Refer to General Policy Guidelines

Publications

References

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Glossary




This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Medical policies are designed to supplement the terms of a member's contract. The member's contract defines the benefits available; therefore, medical policies should not be construed as overriding specific contract language. In the event of conflict, the contract shall govern.

Medical policies do not constitute medical advice, nor the practice of medicine. Rather, such policies are intended only to establish general guidelines for coverage and reimbursement under Mountain State Blue Cross Blue Shield plans. Application of a medical policy to determine coverage in an individual instance is not intended and shall not be construed to supercede the professional judgment of a treating provider. In all situations, the treating provider must use his/her professional judgment to provide care he/she believes to be in the best interest of the patient, and the provider and patient remain responsible for all treatment decisions.

Mountain State Blue Cross Blue Shield (MSBCBS) retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of MSBCBS. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.