Gastroenterology Coding Alert

Surprise: Lower gastro endoscopic procedures aren't limited to colonoscopies

If you're examining how to code only colonoscopies, you're missing three other important endoscopic procedures that involve the lower gastrointestinal tract.

Try Your Hand With These Scenarios

Confront three common coding scenarios, and see how you fare. How would you code each of the following cases:

Hint: To determine whether to code an anoscopy, proctosigmoidoscopy or sigmoidoscopy, look for the specific instrument name, or if necessary, how far your physician advances the scope.

Question 1: A patient visits your physician complaining of intermittent bright red blood in the stool, and the gastroenterologist believes persistent hemorrhoids are causing the condition. The gastroenterologist performs an anoscope.

Question 2: A patient presents to your physician complaining of abdominal cramps, frequent bowel movements and blood in the stool. Your gastroenterologist performs a proctosigmoidoscopy to look for the evidence of colitis.

Question 3: Your gastroenterologist performs a sigmoidoscopy in the office as part of routine colon cancer screening on a non-Medicare patient.

Answer 1: Stick With 46600-46615 for Anoscopy

The anoscope is an appropriate office examination to confirm that active bleeding is from hemorrhoids (for instance, 46600, Anoscopy; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]).

What happens: During an anoscopy, your gastroenterologist uses a short, rigid, hollow tube (anoscope) that may contain a light source to examine the last 5-10 cm of the colon, or anal canal. Applicable anoscopy codes are 46600-46615. The doctor often performs an anoscopy in the office setting.

Note: If your gastroenterologist performs an office visit that is unrelated to the anoscopy, you can report that using the office visit codes (99201-99215). Apply the different diagnosis that supports the separate office visit, and add modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service), says Stephanie Goodfellow, billing supervisor for Mid-America Gastrointestinal Consultants in Kansas City, Mo. Make certain you have documentation to back up your claim.

Answer 2: Learn How Far Proctosig Advances

You should report a proctosigmoidoscopy code, such as 45300 (Proctosigmoidoscopy, rigid; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]).

What happens: For a proctosigmoidoscopy (45300-45327), your gastroenterologist uses a slightly longer instrument than the anoscope to view the inside of the rectum. This exam may include the sigmoid colon as well, and the physician usually advances the scope 6-25 cm into the colon. Gastroenterologists frequently use proctosigmoidoscopies in the office to evaluate diarrhea with bleeding.

Answer 3: Lower Colon Usually Means Sigmoidoscopy

You should report the sigmoidoscopy, which typically passes 26-60 cm into the colon up to the splenic flexure, with 45330-45345.

The flexible sigmoidoscope is roughly 2 feet (61 cm) long and 0.5 in. (1.3 cm) wide with a lighted lens system using a fiberoptic viewing lens or a digital camera, allowing for a more complete view of the lower colon than a rigid scope because the flexibility allows passage around the colon's bends.

Watch out: For Medicare patients, however, you must use G0104 (Colorectal cancer screening; flexible sigmoidoscopy) for a screening sigmoidoscopy rather than 45330-45345.

Also, if you are an ambulatory surgery center (ASC) and you're billing Medicare as the facility, you should append modifier SG (ASC facility service) to your sigmoidoscopy code, says Deborah Carr, CCS, facility coder at PBMS in Chambersburg, Pa. Note: The other procedures are not approved facility procedures.