Incomplete Colonoscopy Coding

How would you code this?

Doctor attempted to perform a colonoscopy on a Medicare patient in the hospital. He encountered a large ulceration in the rectal ampulla that was biopsied AND brushed for cytology. He was then able to advance the scope only to the distal sigmoid colon saying "at this point preparation become completely inadequate for further safe intubation." He then withdrew the scope.

I coded it as 45380 -53 and 45378 -59,-53. Medicare has denied it saying the procedure code is inconsistent with modifier used. I should note that I am coding for the physician, not the facility.

Thanks!

incomplete

45378 – Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen(s) by brushing or washing, with or without collection colon decompression (separate procedure). Because this code is diagnostic and a separate procedure, it should never be reported with any other colonoscopy code. When a diagnostic endoscopy is followed by a surgical endoscopy, the diagnostic endoscopy is considered part of the surgical endoscopy and is not to be separately reported. Only when the provider performs a diagnostic colonoscopy with brushings, washings and/or decompression and nothing else (no biopsies, excisions, etc.) should this code be reported.
45380 – Colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiple. The physician performs colonoscopy and obtains tissue samples. This code can only be reported once regardless of the number of biopsies. This code is also used to describe polypectomy with cold biopsy forceps.
An incomplete colonoscopy is when a doctor plans a colonoscopy but can't complete it. You must consider "the intent of what is to be viewed or biopsied prior to the procedure. Was the intent to do a colonoscopy and for what reason. Was it screening or therapeutic? If the physician never intended to inspect the ascending or transverse colon, he/she wouldn't code a colonoscopy. CMS says to use modifier 53 (Discontinued procedure) to report a colonoscopy if the physician was unable to view farther into the colon than the splenic flexure. For Medicare and payers that follow Medicare guidelines, you should append modifier 53 to 45378 (... diagnostic, with or without collection of specimen[s] by brushing or washing, with or without colon decompression [separate procedure]) for an incomplete colonoscopy. If a therapeutic service (such as a biopsy or polypectomy) was performed and the procedure was incomplete then the appropriate CPT service code (such as 45380, ... with biopsy, single or multiple) would be used with modifier 52 or 53 based on payer. Bottom line, know what was planned, why, and what was actually performed.