Gastroenterology Coding Alert

Multiple endoscopic rules don't apply for simultaneous sigmoidoscopy.

When your gastroenterologist performs a colonoscopy through a stoma, don't make the mistake of reporting this procedure using colonoscopy code sets (45378 -- 45385). You will have to use another set of codes to accurately capture reporting for these procedures.

Check the Basic Procedure

When your gastroenterologist performs an endoscopic procedure through a stomal opening, your reporting primarily depends on the previous surgical procedure when the stoma was created. If the initial procedure was a colectomy with an ileostomy (the end of the ileum is connected to the stoma), you will have to report an endoscopy through stoma using ileoscopy through the stoma codes (44380 -- 44382, Ileoscopy, through stoma...).

If a partial colectomy and a colostomy (the colon is connected to the stoma) were performed earlier, then an endoscopic procedure through stoma should be reported using colonoscopy through stoma codes (44388 -- 44397, Colonoscopy through stoma...).

If the earlier procedure involved the creation of an ileal pouch before it connects to the stomal opening, an endoscopic procedure through stoma should be reported using 44385 -- 44386 (Endoscopic evaluation of small intestinal [abdominal or pelvic] pouch...).

Example: Your gastroenterologist is assessing a patient who underwent a partial colectomy with colostomy for tumor of the colon. He proceeds to visualize the colon endoscopically through the stomal opening. Since the earlier procedure was a colostomy and your gastroenterologist is visualizing the colon, you can report colonoscopy through stoma codes. So you report 44388 (Colonoscopy through stoma; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]).

Observe That not all Procedures Through Stoma are Listed

When reporting an endoscopic procedure through a stoma, you do not have many codes to report all therapeutic procedures that your gastroenterologist performs, especially if you have to report an ileoscopy through stoma or an endoscopic evaluation of a small intestinal pouch. You only have the following reporting options for these procedures:

• 44380 -- Ileoscopy, through stoma; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure)
• 44382 -- Ileoscopy, through stoma; with biopsy, single or multiple
• 44383 -- Ileoscopy, through stoma; with transendoscopic stent placement (includes predilation)
• 44385 -- Endoscopic evaluation of small intestinal (abdominal or pelvic) pouch; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure)
• 44386 -- Endoscopic evaluation of small intestinal (abdominal or pelvic) pouch; with biopsy, single or multiple

The code sets for colonoscopy through stoma are more elaborate and cover most of the procedures that your gastroenterologist might perform through the stomal opening. However, some procedures like a dilation of the stoma using a bougie or a balloon during a colonoscopy through stoma do not have procedural specific codes.

When you have to report a procedure performed by your gastroenterologist that is not covered under these code sets, you will have to resort to using an unlisted code 44799 (Unlisted procedure, intestine) to report the procedure.

Example: Your gastroenterologist assesses a patient with Crohn's disease who has undergone an ileostomy procedure earlier. He performs an ileoscopy through stoma to visualize the ileum. During the procedure, he finds two polyps and removes them using a hot biopsy forceps. Since there is no code for removal of polyps during an ileoscopy through stoma, you will have to report 44799 for the encounter.

Sigmoidoscopy? Report Both Procedures

Most often after a partial or a complete colectomy and stomal creation, your gastroenterologist may need to examine the rest of the lower intestinal structures to assess it for healing or recurrence of the condition for which the initial procedures were conducted.

In such a scenario, your gastroenterologist might resort to performing an endoscopy through the stoma as well as conducting a sigmoidoscopy through the rectum to assess the distal intestinal structures. "A flexible sigmoidoscopy can be billed with a colonoscopy through stoma," says Heather Copen, RHIT, CCS-P, Certified Physician Coder - Goshen OB/GYN and Goshen GI, IU Health Goshen Physicians, Goshen, Indiana. "The rationale is that the two procedures have different entry points as well as visualize different components of the colon." So when your gastroenterologist performs both these procedures, you can report the two procedures together.

Note: Multiple endoscopy rules do not apply when you report an endoscopy through stoma along with a flexible sigmoidoscopy. When you report both these procedures together, you can expect complete payment for both the procedures. "Each payer may have their own policy regarding the two being billed together. So it is important to check with each payer prior to billing," reminds Copen.

However, multiple endoscopy rules apply for two different procedures conducted through the stomal opening. For example, if your gastroenterologist performs a colonoscopy through stoma and removes polyps using snare technique (44394, Colonoscopy through stoma; with removal of tumor[s], polyp[s], or other lesion[s] by snare technique) and hot biopsy forceps (44392, Colonoscopy through stoma; with removal of tumor[s], polyp[s], or other lesion[s] by hot biopsy forceps or bipolar cautery), you can report both the procedures with modifier 59 (Distinct procedural service) appended to 44392.