I am undecided? CPT® 45338? 52 modifier?

OPERATIVE SUMMARY
After correct identification of patient, patient was prepped and draped in sterile fashion after general anesthesia in the supine position lithotomy. After rectal exam was made, it was confirmed that the rectum was too high to be done transanally. Therefore a SILS port was inserted into the rectal orifice and CO2 was insufflated. The tumor was in the mid rectum and the CO2 insufflation was not adequate despite multiple attempts. Good exposure could not be obtained. Therefore endoloop was placed over the tumor and tied to see if the bulk would
eventually become ischemic and necrose. Future plan was to do a either repeat procedure or a colonoscopic snaring. After confirming hemostasis, SILS was removed, dressing applied. Patient extubated in the operating room, transported to the recovery room in stable condition after all
counts were confirmed to be correct.

re: I am undecided? CPT® 45338? 52 modifier?

This is the reference for the code you are thinking of using, This is from the coders desk reference for procedures by optum. This book is a wonderful tool to have when coding procedures


45338

The physician performs flexible sigmoidoscopy and removes tumors, polyps or other lesions. The physician inserts the sigmoidoscope into the anus and advances the scope into the sigmoid colon. The lumen of the sigmoid colon and rectum are visualized. The tumor, polyp, or other lesions are identified and removed by snare technique. The sigmoidoscope is withdrawn at the completion of the procedure.