Gastroenterology Coding Alert

Patient and complaint status may call for additional services

In some cases, you can report E/M and other services separately with hemorrhoidectomy procedures, but in other cases these services are bundled. Knowing the difference will improve your coding and boost your practice's bottom line. Here are the facts.

Code E/M Services and Scopes for New Patients

When the gastroenterologist evaluates a new patient or an established patient with a new problem, you may often report an appropriate-level E/M service and diagnostic scope(s) in addition to any hemorrhoid procedures, says Kathleen Mueller, RN, CPC, CCS-P, coding and reimbursement specialist in Lenzburg, Ill.
 
Example: The gastroenterologist sees a new patient with rectal bleeding. She provides an E/M service that includes a history and exam to determine if the patient has a personal or family history of colon cancer, diverticulitis or other problems.
 
The gastroenterologist also performs a diagnostic proctosigmoidoscopy (45300) or possibly even sigmoidoscopy (45330) or colonoscopy (45378) to determine if a cause other than hemorrhoids is responsible for the bleeding. The scope reveals no problems in the rectum, sigmoid or colon. The gastroenterologist then ligates several hemorrhoids using rubber bands (46221, Hemorrhoidectomy, by simple ligature [e.g., rubber band]).
 
How to code: You may report the E/M service supported by the gastroenterologist's documentation (for instance, 99203) and endoscopic procedure in addition to the hemorrhoidectomy.
 
You must, however, append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M service to differentiate it from the inherent E/M component of the other procedures (hemorrhoidectomy, scopes) provided on the same date, says Marcella Bucknam, CPC, CCS, CCS-P, CPC-H, CPC-P, charge capture manager at the University of Washington Medical Center in Seattle.
 
Therefore, your claim would read 46221 (for ligature hemorrhoidectomy), 9920x-25 (for the E/M service) and 45300 (for proctosigmoidoscopy, for instance). The lower- valued proctosigmoidoscopy code may be subject to the multiple-procedure discount rules depending on the patient's insurance carrier.
 
Alternative: Had the patient in this example been established but with new symptoms of bleeding, the above also applies.

Avoid Scopes for Established Patients

Typically, for established patients with known symptoms, you cannot claim scopes or E/M services in addition to rubber banding or other hemorrhoidectomy codes, Mueller says.
 
For instance, gastroenterologists will often perform an anoscopy (46600) prior to hemorrhoidectomy for an established patient. The National Correct Coding Initiative bundles 46600 to 46221 and considers the anoscopy and any E/M as part of the pre-procedure evaluation for the banding (and therefore not separately payable), says M. Trayser Dunaway, MD, FACS, CSP, CHCO, CHCC, a surgeon, physician and coding educator, and healthcare consultant in Camden, S.C.
 
Something to consider: The NCCI edit coupling 46600 and 46221 includes a -1- status indicator, meaning that if the physician performs an anoscopy for a separate problem (that is, if it is unrelated to the banding procedure), you may report it separately with modifier 59 (Distinct procedural service) appended.
 
Example: For a patient with a history of colon cancer (V10.05), the gastroenterologist may choose to provide a separate scope to check for additional problems beyond hemorrhoids. But in most cases, -you usually won't get paid for more than rubber banding for an established patient unless the patient has significant additional problems,- Mueller says.