Gastroenterology Coding Alert

Confused about those operative notes on the lower GI endoscopy your gastroenterologist just performed? Check out this endoscopy guide for a primer on the upper and lower GI procedure codes.

There are two main types of endoscopies, says Liz McDonald, CPC, coding specialist in the department of surgery at UPMC-Pittsburgh: upper and lower. During an upper GI endoscopy, the gastroenterologist enters the mouth via endoscope and "will view esophagus, stomach, and either the duodenum and/or the jejunum," she says.

During a lower GI endoscopy, on the other hand, the gastroenterologist uses the endoscope to "enter the anus and view from the anus to the cecum," McDonald says.

The first step toward most endoscopy code choices is identifying whether the procedure is an upper or lower GI endoscopy, says Jan Rasmussen, CPC, AGS-GI,ACS-OB, president of Professional Coding Solutions in Eau Claire, Wis.

Once you're satisfied that a service is a lower GI endoscopy, use this advice to further narrow your code choice.

When you're looking at encounter notes trying to decide on the proper endoscopy code, it helps to know where each procedure starts and ends.

Depending on the specifics of the encounter, such as whether the procedure was diagnostic or therapeutic, you'll choose a code from the 46600 (Anoscopy; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]) to 46615 (... with ablation of tumor[s], polyp[s], or other lesion[s] not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique) code set when the endoscope insertion stops in the anus (up to 5 cm).

When the endoscope stops in the anal canal, rectum, or sigmoid colon (6 cm to 25 cm), you'll choose a code from the 45300 (Proctosigmoidoscopy, rigid; diagnostic, withor without collection of specimen[s] by brushing or washing [separate procedure]) to 45327 (.... with transendoscopic stent placement [includes predilation]) set.

If the gastroenterologist inserts the endoscope up to the sigmoid colon, and/or performs an exam of a portion of the descending colon or up to the splenic flexure (26 cm to 60 cm), you'll choose a code from the 45330 (Sigmoidoscopy, flexible; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]) to 45345 (... with transendoscopic stent placement [includes predilation]) set.

If notes indicate that the endoscope goes through the entire colon from the rectum to the cecum and/or the last portion of the small intestine or terminal ileum (60 cm or more) you'll choose a code from the 45378 (Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen[s] by brushing or washing, with or without colon decompression [separate procedure]) to 45392 (... with transendoscopic ultrasound guided intramural or transmural fine needle aspiration/biopsy[s]) set, depending on the specifics ofthat encounter.

Clarification: "A colonoscopy does not have to view the entire colon. I just say make sure it goes past the splenic flexure," before selecting a colonoscopy code, McDonald advises.

Example: A patient reports to the gastroenterologist for a diagnostic GI endoscopy. The notes read "20 cm insertion, ablates two polyps, hot biopsy forceps." Based on these notes, you'd choose 45308 (... with removal of single tumor, polyp, or other lesion by hot biopsy forceps or bipolar cautery) for the encounter.