Gastroenterology Coding Alert

Learning your colonoscopy codes isn't enough -- you need to know how to pull out the best codes using what the doctor gives you.

Take this op note challenge, and see how you fare.

Preoperative diagnosis: Screening colonoscopy.

Postoperative diagnosis: Normal colonoscopy.

Procedure: Colonoscopy.

History: A 56-year-old woman has concerns about colon cancer, and she presents for a colonoscopy.

Operative finding: Normal colonoscopy to the cecum.

Operative procedure: The patient got in the left lateral decubitus position. Under satisfactory IV sedation, the patient underwent an external anal exam and then a digital rectal exam. The physician inserted the Olympus video colonoscope and passed under direct vision to the cecum. The ileocecal valve confirmed this. The physician alternately insufflated and decompressed the bowel as the scope passed back and forth several times through each section. The physician did close inspection behind all valves and folds. The physician retroflexed the scope in the rectum and identified minor hemorrhoids. He decompressed the rectum and removed the scope. The patient awoke, and staff took the patient to the recovery room in a stable condition.

Procedure: For the CPT code, 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]) because you can "assume the patient is not a Medicare one, since she is 56 years old," says Jackie Jones, RHIA, CCS, CPC-H, outpatient coding auditor for Memorial Hermann Healthcare System in Houston, Texas.

If the patient is on Medicare, you would instead report G0121 (Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk).

Diagnosis: For the ICD-9 code, you should report V76.51 (Special screening for malignant neoplasms; colon) as the first-listed code, says Dena Rumisek, biller for Grand River Gastroenterology PC in Grand Rapids, Mich.

You would report 455.0 (Internal hemorrhoids without mention of complication) second. "My reasoning is the patient was scheduled for a screening colonoscopy, and the only finding was the incidental hemorrhoids, which you would report second," Rumisek says.