Home  |   Subscribe  |   Resources  |   Reprints  |   Writers' Guidelines

Ask the Expert

Should there be blanks in transcription e-records?


Theoretically, no. Blanks are indicative of incomplete or unintelligible clinician input, which are not welcome on any health record. That being said, if a clinician electronically authenticates (signs) a document that contains blanks, it will be presented and posted in the EHR “as is,” complete with blanks. GIGO (garbage in, garbage out) is how it has always worked.

— Scott D. Faulkner is principal and CEO of InterFix, LLC.


A Blue Cross/Blue Shield patient is certified for a colonoscopy. The surgeon goes as far as the descending colon and states in his op note that this is a flexible sigmoidoscopy. I used CPT code 45330, but the claim has been denied. Could you use CPT 45378-74?

Libbie McCollough, RHIT
Claiborne County Hospital
Tazewell, Tenn.

An incomplete colonoscopy (sigmoid + descending colon) is coded to 45378 with modifier 73, 74, or 52. (Modifier use depends on circumstances, ie, before or after anesthesia and who is reporting, provider vs. facility).

An incomplete colonoscopy is defined as one where the scope was not able to move beyond the splenic flexure for whatever reason, which seems to be the case here.

The question indicates the intended procedure was a colonoscopy and not a sigmoidoscopy; therefore, 45378 with a modifier appears to be appropriate here. This information is consistent with the Centers for Medicare & Medicaid Services’ Program Memorandum Transmittal AB-03 114 dated August 1, 2003, which instructs facilities to suffix the colonoscopy code (45378) with modifier 73 or 74 as appropriate for incomplete colonoscopies.

NJPR Hospital and Medical Support Services


We bill for physician charges in the office and hospital setting. We are a large physician medical group and have primary care and specialty offices and staff. Sometimes our physicians are asked to meet with attorneys and give sworn statements, depositions, or appear in court for their patients. Is there a section of CPT codes that you would advise using for different legal scenarios when our physicians charge for their time?

Ellie Candela, CPHRM
Grand Rapids, Mich. 

CPT code 99075, Medical testimony, is reserved for occasions when a physician practice reports time spent providing testimony in the judicial system. It is used for billing lawyers and others for whom medically related depositions or testimony is provided.
Physician services need to be billed to the entity to which the services were provided, in this case the law firm. Therefore, while this code would be useful for internal tracking of provider’s time, it would not be appropriate to submit a bill to the health insurer for physician services.

— Anonymous