Anesthesia Coding Alert

Question: Our anesthesiologist put a patient to sleep so the surgeon could look in the colon to determine if a colonoscopy could be performed (the patient had colon polyps). The colonoscopy could not be done, so how should I code the procedure? The physician says to use the code for "exam under anesthesia" instead of a colonoscopy or exploration code.

Florida Subscriber

Answer: Some sections of CPT (such as shoulder, pelvic and eye) include "examination under anesthesia" codes, but the endoscopy codes don't include this. When you're coding this procedure, remember that the coding depends on the carrier and whether the procedure met medical-necessity requirements.
 
If the physician documented medical necessity, two codes are good possibilities. The first is 00902 (Anesthesia for; anorectal procedure) if you're reporting anesthesia codes. (If I understand your question correctly, the physician was determining whether a colonoscopy could be performed, not actually trying to do it.) Most surgeons perform these procedures with a scope. If that's the case and you're reporting surgical codes, use 46600 (Anoscopy; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]). Most patients don't need anesthesia during endoscopy procedures, so be sure you have sufficient diagnosis codes to support medical necessity and be prepared for possible denials from the carrier.