Gastroenterology Coding Alert

Use appropriate modifiers to unbundle codes, when necessary.

To assess a patient with rectal hemorrhage or pain, your gastroenterologist might opt for a proctosigmoidoscopy. Since this procedure is significantly similar to a more extensive sigmoidoscopy, you will have to know how to differentiate these two procedures for accurate coding or face denials to your claims.

1. Ascertain Insertion Approach

Since proctosigmoidoscopy involves examination of the most distal portions of the sigmoid colon and the rectum, your gastroenterologist has to perform this procedure by inserting the scope through the anus. This approach differs from upper endoscopy procedures where the scope is inserted through the mouth.

For example, if the documentation reads, "Scope inserted anally," you can be rest assured that your gastroenterologist performed a lower gastrointestinal (GI) endoscopy and not an endoscopy of the upper GI tract.

2. Check Scope Type

The next step to differentiate between a proctosigmoidoscopy and a flexible sigmoidoscopy is to check the patient notes to see if there is a mention of the type of scope that your gastroenterologist used to perform the procedure. "Documentation should point to the specific type of scope used, rigid or flexible, as well as the parts of the colon examined," says Heather Copen, RHIT, CCS-P, Certified Physician Coder - Goshen OB/GYN and Goshen GI, IU Health Goshen Physicians, Goshen, Indiana.

Since proctosigmoidoscopy involves only examining the distal portions of the sigmoid colon and rectum, your gastroenterologist can use a rigid scope in comparison to a flexible scope when performing a sigmoidoscopy. "If a rigid scope is used to view the rectum and sigmoid colon then CPT® codes 45300-45327 (Proctosigmoidoscopy, rigid...) should be assigned," says Copen. "A rigid scope has limited viewing ability due to the inability to bend at the sigmoid flexure."

Since sigmoidoscopy involves visualizing the rectum, the sigmoid colon and a portion of the descending colon, your gastroenterologist will need a flexible scope to be able to maneuver beyond the splenic flexure and reach into these areas of the GI tract. "If a flexible scope is used to view the rectum, sigmoid colon, and/or the descending colon then codes 45330-45345 (Sigmoidoscopy, flexible...) should be used," adds Copen.

Example: Your gastroenterologist assessed a patient with rectal pain and bleeding. During the encounter, your gastroenterologist advanced a rigid scope to visualize the rectum and the distal sigmoid colon. You can be sure that your gastroenterologist performed a proctosigmoidoscopy. Since your gastroenterologist only visualized the area without performing any other procedures, you can report the encounter with 45300 (Proctosigmoidoscopy, rigid; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]).

3. Ascertain Proctosigmoidoscopy by Scope Distance

During a proctosigmoidoscopy, your gastroenterologist will pass the scope up to a maximum distance of 25 cm. So if your gastroenterologist advances the scope to a distance between 6 cm to 25 cm, you can be assured that he has performed a proctosigmoidoscopy while a distance between 26 cm to 60 cm is indicative that he undertook a sigmoidoscopy.

Example: Your gastroenterologist assesses a patient for hemorrhage of the rectum (569.3, Hemorrhage of rectum and anus). After administration of anesthesia, your gastroenterologist uses a rigid scope that is inserted anally to a distance of 24 cm. Your gastroenterologist notes that the anal canal, rectum and the sigmoid colon was visualized. Since a rigid scope was used and was only advanced to a distance of 24 cm, you can be assured that your gastroenterologist undertook a proctosigmoidoscopy and not a sigmoidoscopy.

4. Look for Therapeutic Intent

Once you have ascertained from the direction of approach, type of scope and extent of scope insertion that your gastroenterologist performed a proctosigmoidoscopy, you will have to look at the patient notes more closely to see if he only visualized the rectum and sigmoid colon or if any other procedures were performed during the same encounter. If your gastroenterologist only visualized the rectum and sigmoid colon, report 45300 for the encounter.

Choose from the following list of codes if your gastroenterologist performed any other procedures during a proctosigmoidoscopy:

• 45303 -- Proctosigmoidoscopy, rigid; with dilation (e.g., balloon, guide wire, bougie)
• 45305 -- ...with biopsy, single or multiple
• 45307 -- ...with removal of foreign body
• 45308 -- ...with removal of single tumor, polyp, or other lesion by hot biopsy forceps or bipolar cautery
• 45309 -- ...with removal of single tumor, polyp, or other lesion by snare technique
• 45315 --...with removal of multiple tumors, polyps, or other lesions by hot biopsy forceps, bipolar cautery or snare technique
• 45317 -- ...with control of bleeding (e.g., injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator)
• 45320 -- ...with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique (e.g., laser)
• 45321 -- ...with decompression of volvulus
• 45327 -- ...with transendoscopic stent placement (includes predilation

Example1: Your gastroenterologist performs a proctosigmoidoscopy to remove rectal polyps. He removed three polyps using the snare technique. You report 45315 for the encounter.

Example2: Suppose he removed two polyps using hot biopsy forceps and one tumor by ablation; you report 45320 for the ablation and 45315 for the removal using hot biopsy forceps. As Correct Coding Initiative (CCI) edits bundles 45320 and 45315 with modifier '1,' you will need to append modifier 59 (Distinct procedural service) to 45315 to report both the services during the same encounter.

5. Look for Any Separate E/M Services

Proctosigmoidoscopy is often done in the office setting using a disposable rigid examination tube and a reusable light source. "Proctosigmoidoscopy does not require the more elaborate and expensive equipment typical of standard endoscopic devices," says Michael Weinstein, MD, Gastroenterologist at Capital Digestive Care in Washington, D.C., and former representative of the AMA's CPT® Advisory Panel. "It also does not require a prolonged preparation or intravenous conscious sedation."

Therefore, the physician can recommend a proctosigmoidoscopy after an office evaluation of the patient and can perform the procedure at the same visit. You can bill for an E&M service (99201-99205, 99212- 99215) if there is documentation of a history, physical, and assessment that includes a plan to perform a proctosigmoidoscopy. The E/M service should be filed with a -25 modifier (Significant, separately identifiable evaluation and management (E/M) services by the same physician on the same day of the procedure or other service) and the proctosigmoidoscopy report should be documented separately from the office visit note.

Example: Your gastroenterologist sees a new patient with a four-week history of diarrhea and bleeding. During the encounter, your gastroenterologist takes a "detailed" history and performs a "detailed" physical exam. The "low complexity" assessment and plan includes a recommendation to immediately perform a proctosigmoidoscopy to look for distal colon inflammatory colitis. The procedure note reads that the rigid instrument was advanced to visualize the rectum and the distal sigmoid colon. A biopsy was obtained from the inflamed mucosa. Since your gastroenterologist documented a separate E/M office visit, you can report the encounter with 99203 (Office or other outpatient visit for the evaluation and management of a new patient...) with the modifier 25 appended to it and 45305 (Proctosigmoidoscopy, rigid; diagnostic, with biopsy, single or multiple).