Gastroenterology Coding Alert

Scoop Up Over $200 by Reporting 44388, 45330 Hassle-Free

In all the excitement of adding new CPT and HCPCS changes to your files for 2011, make sure you put your good old sig coding skills in check or you could find your practice in hot waters for the much dreaded audit.

Think: how would you deal with a sigmoidoscopy that comes with prolonged services or biopsy? Dig into these solutions for the three scenarios given on page 11 and measure how much you know.

45331: Be Careful on Reporting Sig Bundled Services

Scenario 1: A gastroenterologist in our practice was recently treating a patient with a diagnosis of proctitis and continuous rectal bleeding. The gastroenterologist performed a sigmoidoscopy with biopsy during the first encounter. During the second encounter (which took 45 minutes), he infused formalin into the rectum in-office. What CPT codes would I use to bill for the formalin infusion and sigmoidoscopy?

Solution 1: For the first encounter, a standard sigmoidoscopy code would do. For the second encounter, CPT assigns no code for formalin infusion, but obviously this is a lengthy procedure taking much more technical time than a standard flexible sigmoidoscopy and requiring separate medical assessment and counseling. You should consider reporting formalin infusion by billing an E/M and a prolonged services code if the documentation is properly completed. On the claim, you should report:

• 45331 (Sigmoidoscopy, flexible; with biopsy, single or multiple) for the sigmoidoscopy
• 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a problem-focused history; a problem-focused examination; straightforward medical decision making) for the medical assessment and counseling for formalin infusion
• 99354 (Prolonged physician service in the office or other outpatient setting requiring direct [face-to-face] patient contact beyond the usual service first hour [List separately in addition to code for office or other outpatient E/M service]) to account for the extra E/M time
• 569.3 (Hemorrhage of rectum and anus) to 45331,
• 99212 and 99354 to prove medical necessity for the encounter
• 569.49 (Other specified disorders of rectum and anus; other) to 45331, 99212 and 99354 to prove medical necessity for the visit.

Make sure you submit all appropriate documentation to prove medical necessity for the prolonged services code (99354). For example, your documentation should also include an explanation as to the necessity of the prolonged physician service, and a detailed description of what service the gastroenterologist provided during the prolonged service time. To avoid any hassles with the payer, your claim should reflect the gastroenterologist's reasons for the formalin infusion and the most specific ICD-9 codes possible.

Warning: Prolonged services codes are add-on codes, so you shouldn't ever report prolonged service codes alone. These E/M codes clarify whether it was face-to-face time with the patient, and specify exactly the time parameters involved, says

Jennifer Swindle, RHIT, CCS-P, CPC-EM-FP, CCP, director of coding compliance/charge entry for QLIMG, and director of the coding and compliance division of PivotHealth LLC in Garden City, N.Y.

FYI: Be on the lookout for bundles in 45331. If the GI performed biopsies during a sigmoidoscopy, you would consider them part of the procedure. The anorectal exam, when performed pre-procedure, is also part of the surgical package for 45331.

45334 Rules Out Physician-Caused Bleeding

Scenario 2: When a gastroenterologist performs a diagnostic sigmoidoscopy, followed by sigmoidoscopy with control of bleeding, can you report both codes for this encounter?

Solution 2: You would bill 45334 (Sigmoidoscopy, flexible; with control of bleeding [e.g., injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator]), which bundles the work described by another sig code, 45330 (Sigmoidoscopy, flexible; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]).

Because 45330 is a base code, you would report it separately only if the gastroenterologist did not provide any services in the 45331-45345 range. In other words, when your GI performs multiple endoscopic procedures from the same family during the same encounter, the parent (base) code is included within the more extensive same-family procedure codes.

Catch: It's possible that the GI would cause the bleeding during the sigmoidoscopy and then had to control it. "You caused it, you fix it," according to the old adage. Thus, you should only report 45330 or the therapeutic code that precipitated the bleeding (45331, 45338, etc), and not 45334.

44388 + 45330 Carry About $400 Potential Payout

Scenario 3: A patient required both a flexible sigmoidoscopy and a colonoscopy through stoma during the same visit to the office. How should you report it?

Solution 3: On the claim, you should report:

• 44388 (Colonoscopy through stoma; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure])
• 45330 (Sigmoidoscopy, flexible; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure])
• modifier 59 (Distinct procedural service) attached to 45330.

This scenario describes the patient who had prior surgery that required a temporary colostomy as can happen with an attack of diverticulitis (562.11), colon cancer (153.9), or perforation (569.83). Before repairing the colon, it is often necessary to examine the colon above the colostomy opening and also necessary to examine the distal colon from the anus up to the diversion. Remember, 44388 and 45330 do not belong to the same endoscopic family of codes, so carriers should pay 100 percent of the allowable fee for the colonoscopy or $348.94 (10.27 RVUs multiplied by 2011 conversion factor of 33.9764), and you can expect 50 percent of the allowable fee for the flexible sigmoidoscopy or $68.80 (4.05 RVUs multiplied by 2011 conversion factor of 33.9764 divided by two).

What happens: Gastroenterologists can perform flexible sigmoidoscopy and colonoscopy for patients during the same surgical session. A colonoscopy through stoma only looks at that proximal portion of the colon, starting from the level of the stoma. A flexible sigmoidoscopy ensures that the distal colon and rectum are polyp-free.