Gastroenterology Coding Alert

If your lower GI scope coding skills are limited to colonoscopies, you've got some catching up to do.

Most gastroenterology coders can name the colonoscopy codes off the tops of their heads, but those aren't the only lower GI procedures being performed endoscopically. Check out the following three common coding scenarios and see how you fare.

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 anoscopy.

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 without sedation.

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 diagnosis, which may be the same or different, that supports the separate office visit, and add modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) and maintain the documentation that can support the separate nature of the E/M service.

To help avoid denials of the E/M service, the usual documentation of the visit should be maintained, and a "separate distinct" documentation of the procedure is best, advises Glenn Littenberg MD, a gastroenterologist in Pasadena, Calif. Despite that, some payer policies will deny payment for same-day procedures and 25 modified visit services.

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 6-20 cm into the colon. Gastroenterologists frequently perform proctosigmoidoscopies in the office to evaluate diarrhea with bleeding. "Note the word 'rigid' in the descriptor," Littenberg says. "If the procedure report doesn't clarify whether a rigid or flexible scope was utilized, confer with the physician; if the scope is advanced beyond about 20 cm, however, it was almost certainly a flexible scope."

Answer 3: Lower Colon Usually Means Sigmoidoscopy

You should report the sigmoidoscopy, which typically passes 26-60 cm into the colon, sometimes up to the splenic flexure, with 45330-45350.

The flexible sigmoidoscope is roughly two feet long and a half-inch 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 45330-45350.

"Note that moderate sedation for flexible sigmoidoscopy is sometimes provided," Littenberg says. "The duration of sedation is typically 15 minutes or less from first dose of drug until patient stable to get dressed and leave the room; so 99152 is typically used. The Medicare G code G0500 does not apply to flexible sigmoidoscopy (45330) or flexible sigmoidoscopy and biopsy (45331)."