Chromoendoscopy

Widespread application of dye to the lumen of the colon (pan-chromoendoscopy) improves the detection of diminutive lesions (Brown, Baraza & Hurlstone 2007) (I). However, pan-chromoendoscopy is time consuming and the extra lesions detected may be unimportant clinically as a significant number of diminutive lesions may regress (Rother, Knopfle & Bohndorf 2007). The authors of a recent Cochrane review concluded that selective application of dye to suspicious areas (selective chromoendoscopy) may be more appropriate during colonoscopy

This approach is consistent with the conclusions of a recent international workshop which reviewed the role of non-polypoid lesions in the aetiology of colorectal cancer. The endoscopist should be skilled in recognising subtle changes in the appearance of the mucosal surface, particularly alterations in colour, vascularisation and morphology, to identify suspicious areas requiring dye spraying and to better detect polypoid lesions. Small patches of mucus may require rinsing to expose underlying suspicious areas worthy of staining, particularly in the right colon 

Selective chromoendoscopy with dye spraying on the lesion has been shown to be superior to conventional colonoscopy predicting polyp histology (Pohl et al. 2008) (III). Magnification chromoendoscopy is more effective than conventional chromocolonoscopy for diagnosing neoplastic colorectal polyps (Emura et al. 2007)

Colonic cleansing

Inspection of the colon requires careful preparation removing colonic contents to optimise the safety and quality of the procedure. Ideally there should be no residual stool or liquid in the lumen that could mask any suspicious area.  

Flexible sigmoidoscopy 

The ongoing European sigmoidoscopy trials adopted a bowel preparation based on a single enema, self-administered at home within two hours from the appointment, or, in one case, at the screening centre.

No studies were found assessing the effect of having the enema performed directly at the screening centre, although this represents an option that might enhance participation by reducing patient’s concerns and enhancing engagement. Available evidence from one controlled trial did not indicate that using two enemas (the first the night before the test and the second two hours before the scheduled time for the exam) affects participation compared to using a single enema (Senore et al. 1996). Oral preparation was associated with a reduced participation in a large screening trial, compared to enema (Atkin et al. 2000). Adding oral preparation to the enema resulted in reduced participation (Bini et al. 2000). 

No difference in the proportion of inadequate exams was observed when comparing a single enema regimen to a preparation using two enemas or to oral preparation. 

Bowel preparation for screening sigmoidoscopy should involve a single procedure, either enema or oral preparation (II). A single self-administered enema seems to be the preferred option, but cultural factors should be taken into account, and patient preferences should be assessed 

Colonoscopy  

Data on the impact of different preparation regimens in the context of population screening with colonoscopy are lacking. A recent systematic review concluded that no single bowel preparation emerged as consistently superior. Sodium phosphate was better tolerated (Belsey, Epstein & Heresbach 2007), but safety alerts on its use have recently been issued by the US FDA and Health Canada. The authors identified a general need for rigorous study design to enable unequivocal conclusions to be drawn on the safety and efficacy of bowel preparations.

Timing of administration of the recommended dose appears important, as it has been established that split dosing (the administration of at least a portion of the laxative on the morning of the examination) is superior to dosing all the preparation the day before the test, both for sodium-phosphate and polyethylene glycol (Aoun et al. 2005; Parra-Blanco et al. 2006; Rostom et al. 2006; Cohen 2010)

A systematic review (Belsey, Epstein & Heresbach 2007) of different bowel cleansing regimens identified no significant differences other than improved patient tolerance of sodium picosulphate preparations. Furthermore, there are no preferred methods of assessing the effectiveness of bowel cleansing. Care must be taken however with some agents (i.e. phospho prep) in certain patient groups, especially the elderly and those with renal failure, due to potential renal side effects (WHO 2009)

General points to remember

The hospital cannot accept any responsibility for the loss or damage to personal property during your time on these premises. 

If you have any problems with a persistent sore throat, chest or abdominal pain or bleeding please contact your GP immediately informing them that you have had an endoscopy.

If you are unable to contact or speak to your doctor, you must go immediately to the casualty department. If your symptoms persist or worsen, go immediately to casualty. 

It is our aim for you to be seen and investigated as soon as possible after your arrival. However, the department is very busy and your investigation may be delayed. If emergencies occur, these patients will obviously be given priority over less urgent cases.

The hospital cannot except any responsibility for the loss or damage to personal property during your time on these premises.

Dietary instructions for colonoscopy preparation

Low fibre diet 

Fibre is the indigestible part of cereals, fruit and vegetables. Please commence a low fibre diet 2 days before your procedure. 

Foods allowed 

Lean, tender lamb, beef, pork, chicken, turkey, offal, bacon, lean ham, fish, Yorkshire pudding, pancakes; bread sauce; clear and puréed soups; potato (no skins), boiled and mashed; tomato pulp (no skins or pips); fruit juice (if tolerated); pastry made with white flour, white bread, white flour, cornflakes, rice krispies, icing smooth biscuits, eg: Marie, Osborne; spaghetti and pasta; white rice, crisps; rosehip syrup, Ribena; sugar or glucose in small amounts; boiled sweets, toffees; plain or milk chocolate; shortcake, cream crackers, water biscuits; sponge cake, Madeira cake; ice cream, iced lollies; plain or flavoured yoghurt; jelly marmalade; honey, syrup; tea and coffee (without milk) and fizzy drinks. 

Foods to be avoided 

Wholemeal, wheatmeal, granary bread, wholemeal flour; bran biscuits, coconut biscuits; all cereals containing bran or whole wheat, eg; shredded wheat, bran flakes, bran buds, muesli; digestive biscuits; Ryvita, Vita Wheat, oat cakes, etc. 

To enable a more effective examination, we would be grateful if you would take a clear fluid only diet for the period of time stated on the attached appointment letter.

Fluids allowed 

Twenty-four hours before your examination you should take clear fluids only (no food): 

Tea (no milk), black coffee, water, strained fruit juice, strained tomato juice, fruit squash, soda water, tonic water, lemonade, oxo, Bovril, marmite (mixed into weak drinks with hot water), clear soups and broths, consommé.

 In addition 

You may eat clear jellies You may suck clear boiled sweets and clear mints. You may add sugar or glucose to your drinks. 

Fluids not allowed 

Drinks or soups thickened with flour or other thickening agents

Polypectomy

Additional information 

Occasionally polyps are found during the procedure. 

What Are Polyps? 

A polyp is a protrusion from the lining of the bowel, some polyps are pedunculated (look like a mushroom) and are attached to the intestinal wall by a stalk and some are flat polyps which attach directly onto the intestinal wall without a stalk. Polyps when found are generally removed or sampled by the endoscopist as they may grow and cause problems.

Polypectomy 

A polyp may be removed in one of two ways both using an electric current (diathermy). 

For large polyps a snare (wire loop) is placed around the polyp, a high frequency current is then applied and the polyp is removed. 

Flat polyps (without any stalk) can be removed by a procedure called EMR (Endoscopic Mucosal Resection). This involves injecting the lining of the bowel that surrounds the flat polyp. This raises the area and allows the wire loop snare to capture the polyp. 

For smaller polyps biopsy forceps (cupped forceps) are used. These hold the polyp whilst diathermy is applied, therefore destroying the polyp.

After the procedures

You will be allowed to rest for as long as is necessary. Your blood pressure and heart rate will be recorded and if you are diabetic, your blood glucose will be monitored. Should you have underlying difficulties or if your oxygen levels were low during the procedure, we will continue to monitor your breathing and can administer additional oxygen. Once you have recovered from the initial effects of any sedation (which normally takes 30 minutes) you will be offered a snack and moved into a comfortable chair.

Before you leave the department, the nurse or doctor will explain the findings and any medication or further investigations required. She or he will also inform you if you require further appointments. 

Since sedation can make you forgetful it is a good idea to have a member of your family or friend with you when you are given this information although there will be a short written report given to you. 

If you have had sedation you may feel fully alert following the investigation, but however the drug remains in your blood system for about 24 hours and you can intermittently feel drowsy with lapses of memory. If you live alone, try and arrange for someone to stay with you, or if possible, arrange to stay with your family or a friend for at least 4 hours.

 If the person collecting you leaves the department, the nursing staff will telephone them when you are ready for discharge.

Risks of the procedures

Upper gastrointestinal endoscopy and lower gastrointestinal endoscopy are classified as invasive investigations and because of that it has the possibility of associated complications. These occur extremely infrequently, we would wish to draw your attention to them. 

The doctor who has requested these tests will have considered this carefully The risks must be compared to the benefits of having the procedure carried out. 

The risks can be associated with the procedure itself and with the administration of the sedation.

The endoscopic procedure. 

Gastroscopy 

The main risks are of mechanical damage; 

● to teeth or bridgework 

● perforation or tear of the linings of the stomach or oesophagus which could entail you being admitted to hospital. Although perforation generally requires surgery to repair the hole. Certain cases may be treated conservatively with antibiotics and intravenous fluids. 

● bleeding may occur at the site of biopsy and nearly always stops on its own. 

Colonoscopy 

● bleeding (risk approximately 1: 100-200) may occur at the site of biopsy or polyp removal. Typically minor in degree, such bleeding may either simply stop on its own or if it does not, be controlled by cauterization or injection treatment. 

● Perforation (risk approximately 1 for every 1,000 examinations) or tear of the lining of the bowel. An operation is nearly always required to repair the hole. The risk of perforation is higher with polyp removal.

Sedation 

Sedation can occasionally cause problems with breathing, heart rate and blood pressure. If any of these problems do occur, they are normally short lived. Careful monitoring by a fully trained endoscopy nurse ensures that any potential problems can be identified and treated rapidly. 

Older patients and those who have significant health problems – for example, people with breathing difficulties due to a bad chest may be assessed by the doctor before being treated.

Colonoscopy (“The Gold Standard”)

TESTS THAT DETECT CANCER & POLYS

Colonoscopy (“The Gold Standard”)

What happens: The inside of the rectum and entire colon are examined using a long, lighted tube called a colonoscope. 

Flexible Sigmoidoscopy

What happens: Examines your rectum and lower part of the colon with a lighted tube called a sigmoidoscope.

When to get screened (if not high risk): Every five years starting at age 50.

Virtual Colonoscopy

What happens: Uses x-rays and computers to take 2- or 3-dimensional images of your colon and rectum.

When to get screened (if not high risk): Every five years starting at age 50 (though timing has not been closely studied).

Double-Contrast Barium Enema (DCBE)

What happens: Air and barium are pumped into your rectum. The solution will show polyps or tumors on x-rays.

When to get screened (if not high risk): Every five to ten years starting at age 50.

TESTS THAT INDICATE CANCER 

Medicare Colonoscopy Screenings - Age and frequency limit

Watch Age and Frequency Limits for Medicare Colonoscopy Screenings

Medicare benefits allow a covered screening colonoscopy once every 24 months for those patients defined as “high risk” for colorectal cancer, or once every ten years — but not within 48 months of a screening sigmoidoscopy — for those patient’s who do not qualify as “high risk.”

In addition, Medicare guidelines generally require that a screening exam is a covered benefit for those beneficiaries at low risk for colorectal cancer who are 50 years of age or older. This can vary, however, and some carriers specify medical-necessity requirements that allow low-risk beneficiaries under age 50 to receive a covered screening exam.

For beneficiaries at high risk for colorectal cancer, national Medicare policy does not set a minimum age requirement. CMS MedLearn Matters article SE0613 states, “For beneficiaries considered to be at high risk for developing colorectal cancer, Medicare covers one screening colonoscopy every two years, regardless of age.”


Turn to ABN When Exceeding Frequency Limits

Colonoscopy guidelines - Healthnet

 Current Policy Statement of Health Net

Health Net, Inc. considers colonoscopy medically necessary according to the revised guidelines set forth by the American Gastroenterological Association, the American Society of Colon & Rectal Surgeons, the American Cancer Society, the U.S. Multi-Society Task Force on Colorectal Cancer, the American College of Radiology, the National Comprehensive Cancer Network, the American College of Gastroenterology, and the American Society for Gastrointestinal Endoscopy for patients who meet any of the following indications:
 

Diagnostic Colonoscopy

1. Evaluation of an abnormality on barium enema or other imaging study, which is likely to be clinically significant, such as a filling defect or stricture.
2. Evaluation of unexplained gastrointestinal bleeding, such as:
     • Hematochezia not thought to be from rectum or perianal source, especially if the patient is > 40 years old.
    • Melena of unknown origin after an upper GI source has been excluded.
    • Presence of fecal occult blood.
3. Unexplained iron deficiency anemia.

Therapeutic Colonoscopy

Therapeutic Colonoscopy

1. Excision of colonic polyp(s).
2. Treatment of bleeding from such lesions as vascular malformation, ulceration, neoplasia, and polypectomy site (e.g., electrocoagulation, heater probe, laser or injection therapy).
3. Foreign body removal.
4. Decompression of pseudo-obstruction of the colon (Ogilvie's syndrome).
5. Decompression of acute nontoxic megacolon.
6. Treatment of sigmoid volvulus.

What is colonoscopy

Colonoscopy  lets the physician look inside your entire large intestine, from the lowest part, the rectum, all the way up through the colon to the lower end of the small intestine. The procedure is used to diagnose the causes of unexplained changes in bowel habits. It is also used to look for early signs of cancer in the colon and rectum. Colonoscopy enables the physician to see inflamed tissue, abnormal growths, ulcers, bleeding, and muscle spasms. 

For the procedure, you will lie on your left side on the examining table. You will probably be given pain medication and a mild sedative to keep you comfortable and to help you relax during the exam. The physician will insert a long, flexible, lighted tube into your rectum and slowly guide it into your colon. The tube is called a colonoscope (koh-LON-oh-skope). The scope transmits an image of the inside of the colon, so the physician can carefully examine the lining of the colon. The scope bends, so the physician can move it around the curves of your colon. You may be asked to change position occasionally to help the physician move the scope. The scope also blows air into your colon, which inflates the colon and helps the physician see better. 

WHAT ARE THE POSSIBLE COMPLICATIONS OF COLONOSCOPY?

The only possible complication from colonoscopy is a perforation or tear through the bowel which could require surgery. Bleeding may occur from the site of a biopsy or polypectomy. This is usually minor and should stop on its own, or it can be controlled through the colonoscope. Rarely, blood transfusions or surgery may be required.

Potential risks include a reaction to the sedatives/anaesthetic used, and complications from heart or lung disease. Localised irritation of the vein where the medication was injected may cause a tender lump lasting for several weeks but this will go away eventually. Applying heat packs or hot, moist towels may help relieve discomfort. Although complications after colonoscopy are uncommon, it is important for you to recognise early signs of any possible complications: severe abdominal pain, fevers and chills, or rectal bleeding (more than half a cup). Bleeding can occur for several days after polypectomy.

Indications for Colonoscopy and Flexible Sigmoidoscopy

According to the STOP Colon/Rectal Cancer Foundation:

• Beginning at age 50, you should have a screening colonoscopy every 10 years. If you are completely asymptomatic (without any symptoms) and you have no history of colorectal disease, you still need to be screened.

• Beginning at age 40 or earlier, you should have a colonoscopy if you have a personal or family history of benign colorectal polyps, colorectal cancer, ovarian cancer, uterine cancer, breast cancer, ulcerative colitis or Crohn's disease.

According to the 2007 Medicare guidelines for colorectal cancer screening:

• A colonoscopy is recommended once beginning at age 50, then once every 10 years

Most used Colonoscopy CPT codes

COLONOSCOPY - Procedure 

Most used CPT List

45378 Colonoscopy diagnostic

45380 Colonoscopy w biopsy/Colonoscopy w polypectomy(Cold biopsy)

45381 Colonoscopy Tattooing

45382 Colonoscopy w infrared coagulation(laser treatment) for internal hemorrhoid/Colonoscopy w contol of bleeding w endoclip

45384 Colonoscopy w polypectomy(Hot biopsy)

45385 Colonoscopy w polypectomy snare any type( “hot snare,” “monopolar snare,” “cold snare,” or “bipolar snare”)

45386 Colonoscopy w TTS ballon dilatation of stricture

45379 Colonoscopy w foreign body removal with snare

44388 Colonoscopy via colostomy

44394 Colonoscopy via colostomy Snare technique

CPT Code   Description

45384 : Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery (add modifier PT for Medicare or modifier 33 for commercial payers when screening was indication or finding was discovered during screening procedure)

Appendix DD: Inclusions PC 6

Brief description        DD.1 (CPT)         DD.2 (LOINC) 

Colonoscopy 

44388, 44389, 44390, 44391, 44392, 44393, 44394, 44397, 45355, 45378, 45379, 45380, 45381, 45382, 45383, 45384, 45385, 45386, 45387

APPENDIX H: BUNDLED SURGICAL TRAY CROSSWALK

Procedure      Component Code     Procedure Code       Procedure Code Type      Effective Date       Termination Date

STRY3 45384 CPT4 1/1/2007

Coding System: CPT-4

Code INACT UID Description

45378 X Flexible Colonoscopy Proximal to Splenic Flexure

45379 X Flexible Colonoscopy Proximal to Splenic Flexur...

45380 X Flexible Colonoscopy Proximal to Splenic Flexur...

45381 Colonoscopy, Flexible, Proximal to Splenic Flex...

45382 Colonoscopy, Flexible, Proximal to Splenic Flex...

45383 Flexible Colonoscopy Proximal to Splenic Flexur...

45384 Flexible Colonoscopy Proximal to Splenic Flexur...

45385 Flexible Colonoscopy Proximal to Splenic Flexur...

45386 Colonoscopy, Flexible, Proximal to Splenic Flex...

45387 Colonoscopy, Flexible, Proximal to Splenic Flex

WHAT CAN BE EXPECTED DURING THE COLONOSCOPY?

WHAT CAN BE EXPECTED DURING THE COLONOSCOPY?

Colonoscopy is usually well tolerated. There may be a feeling of pressure or bloating during the procedure. Your doctor will give you a medication through a vein which will put you to sleep and you will not feel or remember anything. You will be lying on your left side, or on your back, while the colonoscope is advanced slowly through the large intestine. As the colonoscope is slowly withdrawn, the lining is again carefully examined.

The procedure usually takes between 15 and 30 minutes. In some cases, passage of the colonoscope through the entire colon to its junction with the small intestine cannot be achieved. The doctor will decide if the limited examination is sufficient or if other examinations are necessary.

WHAT IF THE COLONOSCOPY SHOWS SOMETHING ABNORMAL?

WHAT ARE POLYPS AND WHY ARE THEY REMOVED?

WHAT ARE POLYPS AND WHY ARE THEY REMOVED?

Polyps are abnormal growths from the lining of the colon. They vary in size from a tiny dot to several centimetres. The majority of polyps are benign (non-cancerous) but we cannot always tell a benign polyp from a malignant (cancerous) polyp by its outer appearance alone. For this reason, removed polyps are sent for analysis by a pathologist. Removal of colon polyps is an important means of preventing colorectal cancer