Gastroenterology Coding Alert

Don't be confused by how far the scope goes

Distinguishing between different scope procedures is a simple matter of knowing the anatomy. The next step is determining how far the doctor inserted the scope. Our experts make it easy with some examples.

When a gastroenterologist performs a scoping procedure, it can be a simple examination (diagnostic), or it may involve any number of interventions, says Margie Pfaff, CPC, corporate compliance analyst for Wisconsin's Medical Associates Health Centers. Each procedure includes a diagnostic component, meaning the doctor does not perform any interventions, Pfaff says. CPT considers interventions separate procedures, and you cannot bill them in addition to another scope procedure at the same session, she says.

Recognize Your Scopes

The four main procedures using rectal scopes are anoscopy, proctosigmoidoscopy, sigmoidoscopy and colonoscopy. Each of these basic procedures uses a different instrument and forms the base of a family of CPT Codes . You can determine which procedure to code for by looking for the specific instrument name or, if necessary, by how far the doctor inserts the scope.

Stick With 46600-46615 for Anoscopy

During an anoscopy, the gastroenterologist uses a short, rigid, hollow tube (anoscope) that may contain a light source to look at the last 2-4 inches (5-10 centimeters) of the colon (anal canal). The range of CPT codes is 46600-46615, Pfaff says.

The physician often performs an anoscopy in the office setting. Example: A patient visits the gastroenterologist complaining of intermittent bright red blood from what he believes is persistent hemorrhoids, says Joel V. Brill, MD, chief medical officer for Predictive Health LLC in Phoenix. The short anoscope is an appropriate office examination to confirm that active bleeding is from the hemorrhoids. Use 46600 (Anoscopy; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]) for the patient evaluation.

Proctosigmoidoscopy Advances to the Rectum

During a proctosigmoidoscopy, the gastroenterologist uses a slightly longer instrument than the anoscope to view the inside of the rectum, Pfaff says. This exam may include the sigmoid colon as well. The physician typically advances the scope 6-25 cm into the colon, Pfaff says. The range of CPT codes for proctoscopy is 45300-45327, she says.

Doctors frequently do proctoscopies in the office for evaluation of diarrhea with bleeding. Example: A patient goes to a gastroenterologist complaining of abdominal cramps, frequent bowel movements and blood. There is also a history of recent antibiotics and travel to Mexico. The physician performs the proctoscope exam to look for any evidence of colitis. For the evaluation, bill 45300 (Proctosigmoidoscopy, rigid; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]). In some cases, the physician will obtain a biopsy during the proctoscope exam to determine what is causing the colitis. For the proctoscope with biopsy, bill 45301 (- with dilation [e.g., balloon, guidewire, bougie]).

In the Lower Colon? You-ll Likely Use Sigmoidoscopy

The flexible sigmoidoscope is about 2 feet (61 cm) long and 0.5 inches (1.3 cm) wide with a lighted lens system, Pfaff says. A flexible sigmoidoscope allows a more complete view of the lower colon than a rigid scope because its flexibility allows passage around the bends within the colon, Pfaff says. The exam typically involves examination of the colon from 26-60 cm, she adds, and the range of CPT codes for sigmoidoscopy is 45330-45345.

Gastroenterologists often perform sigmoidoscopies in the office as part of a program for routine colon cancer screening. Example: The gastroenterologist will perform a flexible sigmoidoscopy about every four or five years. Use 45330 (Sigmoidoscopy, flexible; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]) for the procedure, Brill says. If the patient has Medicare for insurance coverage, you should report the routine flexible sigmoidoscopy for colon cancer screening with G0104 (Colorectal cancer screening; flexible sigmoidoscopy).

Colonoscopy Depends on Your Payer's Definition

The colonoscope is a thin, flexible instrument that ranges from 48 inches (121.9 cm) to 72 inches (182.9 cm) long, Pfaff says. CPT considers colonoscopies to be complete if the examination goes past the splenic flexure, but they typically include the cecum and ileum, she adds. This is typically an exam of more than 60 cm, indicating that you would report this services from the code range 45378-45392.

According to Medicare, however, a complete colonoscopy examination includes the cecum, Brill says. And Medicare uses a different modifier (53, Discontinued procedure) based on its payment policy than CPT (modifier 52, Reduced services) when the colonoscopy extends past the splenic flexure but does not reach the cecum, he says.

Colonoscopies typically aren't done in the standard physician's office. Example: The gastroenterologist is treating a patient who complains of a change in bowel habits and blood in the stool. The physician schedules a procedure at the hospital endoscopy suite and performs a colonoscopy. Use 45378 (Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen[s] by brushing or washing, with or without colon decompression [separate procedure]) for the procedure, Brill says. If the gastroenterologist performs a biopsy during the examination, use 45380 (- with biopsy, single or multiple).