I’m in need of your opinions on the coding of the below op report. Optum is denying my claims stating that the services are not supported due to no documentation within the op report that the colonoscope went to the cecum. Per CPT book the definition of a colonoscopy is the examination of the entire colon, from the rectum to the cecum, and may include the examination of the terminal ileum or small intestine proximal to an anastomosis.

A digital rectal exam was performed revealed no masses. After adequate IV sedation given, Olympus pediatric colonoscope was inserted into the patient’s rectum and advanced around the ileocolonic anastomosis. The patient had scarring with the ascending colon from previous Crohn disease. The anastomosis was strictured down and the scope could not be advanced through this area. A 12-13.5-15 mm wire-guided balloon was advanced through the anastomosis. The balloon was inflated to 12mm held there for 1 minute. The balloon was inflated to 13.45 mm and held there for 1 minute. The balloon could be advanced through the anastomosis. Some active inflammation and ulceration was noted within the terminal ileum. Biopsies were obtained from the terminal ileum. The remainder of the ascending colon, hepatic flexure, transverse colon, splenic flexure, descending colon, sigmoid colon and rectum were normal.

Coded As:
:confused:
45386
45380-59

Thank you in advance for your opinions.