Understanding Incomplete Colonoscopy diagnosis, documentation, and medical coding? Find information on reasons for incomplete colonoscopy, including bowel prep quality, obstructing lesions, and patient intolerance. Learn about appropriate ICD-10-CM codes, Z codes for screening colonoscopies, and CPT codes for diagnostic colonoscopies. Explore resources on proper colonoscopy documentation for healthcare professionals, clinical guidelines, and quality measures related to incomplete colonoscopies. Improve your understanding of incomplete colonoscopy procedures and optimize your clinical documentation and coding practices.
Also known as
Other diseases of intestines
This code specifies incomplete colonoscopy.
Other specified intestinal disorders
May be used for unspecified reasons causing incomplete colonoscopy.
Procedures not carried out
Covers reasons why a procedure, like a colonoscopy, wasn't completed.
Follow this step-by-step guide to choose the correct ICD-10 code.
Was the colonoscopy aborted due to patient intolerance?
Yes
Code R13.22, Examination of large intestine incomplete
No
Was it stopped due to an obstruction?
When to use each related code
Description |
---|
Incomplete Colonoscopy |
Aborted Colonoscopy |
Difficult Colonoscopy |
Poor bowel prep hinders visualization, leading to incomplete exam and potential missed diagnoses, impacting code accuracy (e.g., 45378 vs. 45380).
Inability to reach cecum due to anatomical issues or patient tolerance requires accurate coding for incomplete study and follow-up recommendations (e.g., 45378).
Complications (e.g., perforation) during colonoscopy require accurate coding for both the procedure and the complication itself, impacting reimbursement and quality metrics.
Incomplete colonoscopy performed today. Procedure incomplete due to (reason for incomplete colonoscopy - e.g., inadequate bowel preparation, patient intolerance due to pain, inability to intubate cecum, obstructing lesion, equipment malfunction). The patient presented for screeningcolonoscopy, surveillance colonoscopy, or diagnostic colonoscopy (choose one and specify indication, e.g., history of polyps, family history of colorectal cancer, change in bowel habits, iron deficiency anemia, rectal bleeding). Pre-procedure assessment included review of medical history, current medications, and allergies. Informed consent was obtained. The patient was placed in the left lateral decubitus position. (Specify sedation and analgesia administered, e.g., moderate sedation with fentanyl and midazolam). A (specify endoscope type) colonoscope was advanced. The examination reached (specify farthest point reached, e.g., the splenic flexure, 60 cm from the anal verge). (Describe findings, e.g., The mucosa to that point was normal. Diverticulosis was noted in the sigmoid colon. A polyp was identified and removed via (polypectomy technique) at (location). Photos and videos were taken and are available for review). Due to (reason for incompletion), the cecum was not reached. The patient tolerated the procedure (well or poorly). Post-procedure, the patient was monitored in the recovery area until stable. (Document any immediate complications). Recommendations include (repeat colonoscopy with improved bowel prep, virtual colonoscopy, other imaging modality, or alternative management strategy). The importance of completing the colonoscopy was discussed with the patient, including risks and benefits. Follow-up instructions provided. Diagnosis: Incomplete colonoscopy.