Forum - Questions & Answers
Colonoscopy documentation
We are a gastroenterology practice that recently added a document writer for our physicians. The question comes from their currently documentation for a colonscopy. The CPT® code of 45378 says "with visualization of the cecum" and our providers previously dictated that but now they are saying "to the terminal ileum" which is implying they are seeing the cecum as they have to be in the cecum to get to the terminal ileum. So the question is: If the providers state they have reached the terminal ileum, is that sufficient documentation for the colonoscopy? Thank you.